Stroke: Physiotherapy Treatment Approaches: Difference between revisions

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Practising reaching beyond arm’s length while sitting with supervision/assistance should be undertaken for individuals&nbsp;who have difficulty with sitting.'''&nbsp;<ref name="Cabanas" /> '''
Practising reaching beyond arm’s length while sitting with supervision/assistance should be undertaken for individuals&nbsp;who have difficulty with sitting.'''&nbsp;<ref name="Cabanas" /> '''
</blockquote>  
</blockquote>  
==== Standing ====
==== Standing ====
<blockquote>'''Strong Recommendation'''</blockquote><blockquotePractice of standing balance should be provided&nbsp;for individuals who have difficulty with standing. Strategies could include:  
<blockquote>
#Practising functional task-specific training while standing <ref>Bang DH, Cho HS. Effect of body awareness training on balance and walking ability in chronic stroke patients: a randomized controlled trial. Journal of physical therapy science. 2016;28(1):198-201.</ref>&nbsp;<ref name="JM 2014" />&nbsp;<ref name="van" />&nbsp;<ref name="Pollock" />
'''Strong Recommendation'''
</blockquote> <blockquote>
Practice of standing balance should be provided&nbsp;for individuals who have difficulty with standing. Strategies could include:
</blockquote><blockquote>
#Practising functional task-specific training while standing <ref>Bang DH, Cho HS. Effect of body awareness training on balance and walking ability in chronic stroke patients: a randomized controlled trial. Journal of physical therapy science. 2016;28(1):198-201.</ref>&nbsp;<ref name="JM 2014" />&nbsp;<ref name="van" />&nbsp;<ref name="Pollock" />  
#Walking training that includes challenge to standing balance (e.g. overground walking, obstacle courses)&nbsp;<ref name="van">van Duijnhoven HJ, Heeren A, Peters MA, Veerbeek JM, Kwakkel G, Geurts AC, Weerdesteyn V. Effects of Exercise Therapy on Balance Capacity in Chronic Stroke. Stroke. 2016 Oct 1;47(10):2603-10.</ref>  
#Walking training that includes challenge to standing balance (e.g. overground walking, obstacle courses)&nbsp;<ref name="van">van Duijnhoven HJ, Heeren A, Peters MA, Veerbeek JM, Kwakkel G, Geurts AC, Weerdesteyn V. Effects of Exercise Therapy on Balance Capacity in Chronic Stroke. Stroke. 2016 Oct 1;47(10):2603-10.</ref>  
#Providing visual or auditory feedback <ref name="2017" />&nbsp;<ref name="JM 2014" />&nbsp;<ref>Stanton R, Ada L, Dean CM, Preston E. Biofeedback improves activities of the lower limb after stroke: a systematic review. Journal of physiotherapy. 2011 Dec 31;57(3):145-55.</ref>  
#Providing visual or auditory feedback <ref name="2017" />&nbsp;<ref name="JM 2014" />&nbsp;<ref>Stanton R, Ada L, Dean CM, Preston E. Biofeedback improves activities of the lower limb after stroke: a systematic review. Journal of physiotherapy. 2011 Dec 31;57(3):145-55.</ref>  
#Receive progressive balance training
#Receive progressive balance training  
#Recieve lower limb&nbsp;strengthening exercises&nbsp;<ref name="2016" />
#Recieve lower limb&nbsp;strengthening exercises&nbsp;<ref name="2016" />  
#Consider for an ankle-foot orthosis&nbsp;<ref>Tyson SF &amp; Kent RM, 2013. Effects of an ankle-foot orthosis on balance and walking after stroke: a systematic review and pooled meta-analysis. Archives of Physical Medicine &amp; Rehabilitation, 94, 1377-85.</ref>
#Consider for an ankle-foot orthosis&nbsp;<ref>Tyson SF &amp;amp; Kent RM, 2013. Effects of an ankle-foot orthosis on balance and walking after stroke: a systematic review and pooled meta-analysis. Archives of Physical Medicine &amp;amp; Rehabilitation, 94, 1377-85.</ref>
</blockquote>
<br></blockquote>


=== Gait &amp; Mobility ===
=== Gait &amp; Mobility ===

Revision as of 22:47, 21 May 2017

Introduction[edit | edit source]

A wide range of treatment techniques and approaches from different philisophical backgrounds are utilised in Neurological Rehabilitation. Research to support the different approaches varies hugely, with a wealth of research to support the use of some techniques while other approaches have limited evidence to support its use but rely on ancedotal evidence. This page provides a brief overview of some of the approaches used in Stroke Rehabilitation with evidence based clinical guideline recommendations.

State of the Evidence[edit | edit source]

The past decade has seen an exponential growth in the number of Randomised Control Trials in relation to physiotherapy interventions utilised in Stroke. Veerbeek et al (2014) highlight that the number of RCTs on Stroke Interventions has almost quadrupled in the past 10 years, with strong evidence seen in 30 out of 53 interventions for beneficial effects on one or more outcomes. They suggest the main change lies in the increased number of interventions to which ‘strong evidence’ could be assigned and an increase in the number of outcomes for which the findings are statistically significant. [1]

Higher intensity of practice appears to be an important aspect of effective physical therapy and suggestion is that intensity of practice is a key factor in meaningful training after stroke, and that more practice is better. 17 hours of therapy over a 10 week period has been found to be necessary for significant positive effects at both the body function level as well as activities and participation level of the ICF. Yet despite the fact that National Clinical Guidelines advocate for at least 45 mins of therapy daily as long as there are rehabilitation goals and the patient tolerates this intensity, and recognition that high-intensity practice is better there still remains a big contrast between the recommended and actual applied therapy time. Recent surveys in the Netherlands showthat patients with stroke admitted to a hospital stroke unit only received a mean of 22 minutes of physical therapy on weekdays. Similarly, in the United Kingdom inpatients received 30.6 minutes physical therapy per day. Both of these significantly fall short of the recommended 45 mins daily. [1]

While the body of knowledge in relation to physiotherapy in stroke rehabilitation is still growing further confirmation of the evidence for physiotherapy after stroke, and facilitating the transfer to clinical practice, requires a better understanding of the neurophysiological mechanisms, including neuroplasticity, that drive stroke recovery, as well as the impact of physiotherapy interventions on these underlying mechanisms. Similarily further research is required to support physiotherapy implementation strategies in order to optimize the transfer of scientific knowledge into clinical practice.

High growth in evidence does in its own way create challenges for physiotherapists in keeping up to date with new evidence as it becomes available and there is a need for further investigation into more effective and efficient methods for physiotherapists to keep their knowledge and skill level up-to-date in the long term.[1]

The following Fig.1 graphically displays therange of outcomes classified according to the ICF, with corresponding interventions for which is strong evidence that they significantly affect those outcomes. It should be noted that the clinical applicability of some interventions like electromechanical-assisted gait training and robot-assisted arm training is questionable, due to the accompanying high costs of the equipment. For these interventions, there are often alternative ‘strong evidence’ interventions available. [1]

Overview of Outcomes for which Interventions are available with Significant Summarized Effects. Legend: A green point indicates that the intervention has a significant positive effect on the outcome, while a red point indicates that the intervention has a significant negative effect on the outcome;

Figure 1. Overview of Outcomes for which Interventions are available with Significant Summarized Effects

This graphically displays the outcomes classified according to the ICF, with corresponding interventions for which is strong evidence that they significantly affect those outcomes. Legend: A green point indicates that the intervention has a significant positive effect on the outcome, while a red point indicates that the intervention has a significant negative effect on the outcome; [1]

Interventions [edit | edit source]

Positioning[edit | edit source]

Ability to change position and posture is affected in many individuals post stroke as a result of varying degrees of physical impairments. Therapeutic positioning aims to reduce skin damage, limb swelling, shoulder pain or subluxation, and discomfort, and maximise function and maintain soft tissue length. It is also suggested that positioning may assist in reduction of respiratory complications such as those caused by aspiration and avoid compromising hydration and nutrition. The aim of positioning the patient is to try to promote optimal recovery and comfort by modulating muscle tone, providing appropriate sensory information, increasing spatial awareness, improved ability to interact with the environment and prevention of complications such as pressure sores, and contracture. [1] [2] [3]

The most appropriate position in which to place a patient following a stroke remains unclear. There is no Randomised Control Trial evidence to support the recommendation of any one position over another but five main positions have been recommened, a survey of physiotherapists’ current positioning practices found the most commonly recommended positions to be: sitting in an armchair as recommended by 98% of respondents; side lying on the unaffected side then side lying on the affected side. Sitting in a wheelchair (78%, 95% CI 74 to 82%) and supine lying were less commonly recommended. [4]

Practice Statement
Consensus-based Recommendation

  1. Initial specialist assessment for positioning should occur in acute stroke as soon as possible and where possible within 4 hours of arrival at hospital.
  2. Arm Support devices such as a Lap Tray may be used to assist with arm positioning for those at risk of shoulder subluxation
  3. Education and training around correct manual handling and positioning should be provided to the individual with stroke, their family/carer and health professionals, particularly nursing and other allied health staff.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
  4. Elevation of the limb when resting should be considered for individuals who are immobile to prevent swelling in the hand and foot. [5]

Early Mobilisation[edit | edit source]

Immobility is associated with a number of post stroke complications such as deep vein thrombosis etc. Early mobilization aims to reduce the time that elapses between stroke and the first time the patient leaves the bed, increasing the amount of physical activity that the patient engages in outside of bed. Early mobilisation (e.g. activities such as sitting out of bed, transfers, standing and walking) aims to minimise the risk of the complications of immobility and improve functional recovery.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title There remains some ongoing discssion about the exact meaning of very early mobilization but Verbeek et al (2014) define early mobilization as ‘mobilizing a patient out of bed within 24 hours after the stroke, and encouraging them to practice outside the bed'. [6] [4] Recent changes in recommendations have been  made as a result of the AVERT Trial RCT of over 2000 individuals with acute stroke, which showed that very early, more frequent, higher dose mobilisation focused on out-of-bed activities in addition to usual care was worse than usual care alone and led to greater disability at three months with no effect on immobility-related complications or walking recovery.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Strong Recommendation FOR

  1. Patients with difficulty moving after stroke should be assessed as soon as possible within the first 24 hours of onset by an appropriately trained healthcare professional to determine the most appropriate and safe methods of transfer and mobilisation. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
  2. Commence mobilisation (out of bed activity) within 24 - 48 hrs of stroke onset unless receiving palliative care.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Strong Recommendation AGAINST

  1. Starting intensive out of bed activities within 24 hours of stroke onset is not recommended. Mobilisation within 24 hours of onset should only be for patients who require little or no assistance to mobilise. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Balance[edit | edit source]

Balance difficulties are commone for many individuals post stroke usually due to a combination of reduced limb and trunk motor control, altered sensation and sometimes centrally determined alteration in body representation such that the person misperceives their posture in relation to the upright. Impaired balance often leads to reduced confidence, fear of falling and increases the risk of falls. Current evidence suggests that trunk exercise training improve trunk performance and dynamic sitting balance [7], while task specific training improves dynamic balance in both sitting and standing.[8] Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title [1]

Sitting[edit | edit source]

Strong Recommendation

Practising reaching beyond arm’s length while sitting with supervision/assistance should be undertaken for individuals who have difficulty with sitting. [7]

Standing[edit | edit source]

Strong Recommendation

Practice of standing balance should be provided for individuals who have difficulty with standing. Strategies could include:

  1. Practising functional task-specific training while standing [9] [1] [10] [8]
  2. Walking training that includes challenge to standing balance (e.g. overground walking, obstacle courses) [10]
  3. Providing visual or auditory feedback Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title [1] [11]
  4. Receive progressive balance training
  5. Recieve lower limb strengthening exercises Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
  6. Consider for an ankle-foot orthosis [12]


Gait & Mobility[edit | edit source]

Strong Recommendation
Tailored repetitive practice of walking (or components of walking) should be practiced as often as possible for individuals with difficulty walking. The following modalities can be used to achieve this:Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

  1. Circuit Class Therapy (with a focus on overground walking practice) [13] 
  2. Treadmill Training with or without body weight support [14]
  3. Virtual Reality Training [15] [16]

Weak Recommendation
Other interventions may be used in addition to those above:

  1. Electromechanically Assisted Gait Training [17]
  2. Biofeedback [18]
  3. Cueing of Cadence [19]
  4. Functional Electrical Stimulation [20]

Treadmill[edit | edit source]

Electromechanical Assisted[edit | edit source]

Rhythmic Cueing[edit | edit source]

Virtual Reality[edit | edit source]

Overground Walking[edit | edit source]

Community Walking[edit | edit source]

Weak Recommendation

  1. Individualised goals should be set and assistance with adaptive equipment, information, and further referral on to other agencies should be provided for individuals who have difficulty with outdoor mobility in the community.
  2. Walking practice may benefit some individuals and if provided, should occur in a variety of community settings and environments, and may also incorporate virtual reality training that mimics community walking. [21] Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Orthotics[edit | edit source]

Weak Recommendation

  1. Individually fitted lower limb orthoses may be used to minimises limitations in walking ability. Improvement in walking will only occur while the orthosis is being worn. [22] Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title [23]

Upper Limb[edit | edit source]

Up to 85% of indviduals post stroke experience altered arm function, with approximately 40% of individuals being affected by upper limb function long term. Loss of arm function adversely affects quality of life, and functional motor recovery in affected upper extremities in patients with hemiplegia is the primary goal of physical therapists. "Currently there is no high quality evidence for any interventions that are routine practice, and evidence is insufficient to enable comparison of the relative effectiveness of interventions.” In other words, the evidence is insufficient to show which of the interventions are the most effective for improving upper limb function” Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Strong Recommendation

  1. People with stroke with potential or actual arm movement should be given every opportunity to practice functional activities that incorporate movements that are of high intensity, repetitive and are task-specific. These activities may be bilateral or unilateral depending on the task. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Bilateral Arm Training[edit | edit source]

Bilateral Arm Training provides intensive training of bilateral coordination to enable practice of bimanual skills. During bilateral arm training, movement patterns or activities are performed with both hands simultaneously but independent from each other and can also be cyclic. This approach was developed in response to identified limitations of Constraint Induced Movement Therapy (CIMT) which precludes the opportunity to practice bilateral skills particularly functional activities that are inherently bimanual. Unilateral and bilateral training are similarly effective. However, intervention success may depend on severity of upper limb paresis and time of intervention post-stroke.

Weak Recommendation

  1. Bilateral arm training may be used as part of comprehensive goal directed rehabilitation. However, when matched for dosage, unilateral training may be more effective. [1] [24] [25] Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Constraint Induced Movement Therapy[edit | edit source]

Constraint-induced movement therapy (CIMT) involves intensive targeted practice with the affected limb while restraining the non-affected limb, which means that during task-specific practice, individuals with hemiplegic stroke are forced to use their affected limb. Following a neurological incident, often the affected arm and hand are not used sufficiently even if there is some functional activity present. To address this ‘Learned non-use’, the approach of CIMT was developed whereby the non-affected limb was constrained hereby forcing the affected limb to work. This forced-use therapy combined with shaping and goal-directed training is now commonly known as CIMT. [26] [27] 

Different categories of CIMT can be distinguished for use in Stroke depending on the duration of the immobilization of the paretic arm and the intensity of task-specific practice: [1]

Original CIMT Applied for 2 to 3 weeks consisting of immobilization of the non-paretic arm with a padded mitt for 90% of waking hours utilising task-oriented training with a high number of repetitions for 6 hours a day; and behavioral strategies to improve both compliance and transfer of the activities practiced from the clinical setting to the patient’s home environment.

High-intensity mCIMT Consists of immobilization of the non-paretic arm with a padded mitt for 90% of waking hours with between 3 to 6 hours of task-oriented training a day. Found to be more beneficial in the acute stage pf rehabilitation with less effect on chronic upper limb impairment.

Low-intensity mCIMT Consisted of immobilization of the non-paretic arm with a padded mitt for > 0% to < 90% of waking hours with between 0 to 3 hours of task-oriented training a day. 

Strong Recommendations

  1. Intensive Constraint Induced Movement Therapy (minimum 2 hours of active therapy per day for 2 weeks, plus restraint for at least 6 hours a day) should be provided to improve arm and hand use for individuals with 20 degrees of active wrist extension and 10 degrees of active finger extension. [28] Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
  2. Trunk restraint may also be incorporated into the active therapy sessions at any stage post-stroke. [29] Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Electrical Stimulation[edit | edit source]

Functional Electrical Stimulation appears to moderately improve upper limb activity compared with both no intervention and training alone. Current evidence suggest that electrical stimulation should be used in stroke rehabilitation to improve the ability to perform functional upper limb activities.

Strong Recommendation

  1. Use of electrical stimulation in conjunction with motor training should be used to improve upper limb function after stroke . [30] Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Robot Assisted Arm Training[edit | edit source]

Robot-mediated treatment utilises automated devices to provide passive, active or resistive limb movement which could allow for extended periods of treatment and treatments that are responsive to the particular needs of the individual by using the person’s movement as feedback, as ability changes over time. There is currently conflicting evidence as there is still limited evidence to suggest when or how often robot assisted arm movement should be used. People with reduced arm function after a stroke should only be offered robot-assisted movement therapy or neuromuscular electrical stimulation as an adjunct to conventional therapy in the context of a clinical trial. [31] Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Strong Recommendation

  1. Robot /Mechanical assisted arm training should be used to improve upper limb function in indivduals with mild to severe arm weakness after stroke "as an adjunct to conventional therapy in the context of a clinical trial". Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Virtual Reality[edit | edit source]

The evidence base for virtual reality and interactive video gaming-based interventions for the arm (as an adjunct to usual care to increase overall therapy time) is developing, though studies are often of low quality and further research is needed.

Strong Recommendation

  1. Virtual Reality and interactive games should be used to improve upper limb function in individuals with mild to moderate arm impairment after stroke. Virtual reality therapy should be provided for at least 15 hours total therapy time. (Laver et al 2015 [96])Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Mirror Therapy[edit | edit source]

Weak Recommendation

  1. Mirror Therapy may be used as an adjunct to routine therapy to improve arm function after stroke for individuals with mild to moderate weakness, complex regional pain syndrome and/or neglect. (Thieme et al 2012 [162])Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Mental Practice[edit | edit source]

Motor imagery (MI) is a mental process of rehearsal for a given action in order to improve motor function while Mental Practice (MP) is a training method during which a person cognitively rehearses a physical skill using MI in the absence of overt, physical movements for the purpose of enhancing motor skill performance. Mental practice with motor imagery ‒ the practising of movements and activities ‘in the mind’ ‒ has been advocated to aid recovery following stroke. Current Systematic Reviews support the use of mental practice as an adjunct to conventional therapy techniques for arm rehabilitation in the acute, sub-acute and chronic phases of stroke, particulalry in those with more severe impairment of the upper limb. [32] Interestingly, Mental Practice using Motor Imagery increases affected arm use, thus overcoming this movement suppression phenomenon and combined with Physical Practice training was better for the restoration of hand function than Physical Practice alone.

Weak Recommendation

  1. Mental practice, where no cognitive impairment exists, in conjunction with active motor training may be used to improve arm function for individuals with mild to moderate weakness of their arm. [33] [34] [35] Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title 

Splinting[edit | edit source]

Strong Recommendation AGAINST

  1. Routine practice should not include Hand and wrist orthoses (splints) as they have no effect on function, pain or range of movement (Tyson et al 2011 [129])Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Cardiorespiratory Training[edit | edit source]

Strong Recommendation

  1. Rehabilitation should include individually tailored exercise interventions to improve cardiorespiratory fitness.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Practice Statement
Consensus-based Recommendations

  1. Commence cardiorespiratory training during their inpatient stay.
  2. Encourage to participate in ongoing regular physical activity regardless of level of disability.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Strength Training[edit | edit source]

Strong Recommendation

  1. Progressive resistance training should be offered to those with reduced strength in their arms or legs. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Circuit Class[edit | edit source]

Aquatherapy[edit | edit source]

Electrotherapy[edit | edit source]

Weak Recommendation

  1. Electrical stimulation may be used for those with reduced strength in their arms or legs (particularly for those with less than antigravity strength).
  2. Electrical stimulation may be used to prevent or reduce shoulder subluxation. (Vafadar et al 2015 [75])Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Neuromuscular Electrical Stimulation[edit | edit source]

TENS[edit | edit source]

Electromyographic Biofeedback[edit | edit source]

Spasticity Management[edit | edit source]

Stretch[edit | edit source]

Weak Recommendation AGAINST

  1. Routine use of stretch to reduce spasticity is not recommended.(Katalinic et al 2010 [64]; Kim et al 2013 [65]; Jung et al 2011 [66])
  2. Adjunct therapies to Botulinum toxinum A such as electrical stimulation, casting, taping and stretching may be used to reduce spasticity. (Stein et al 2015 [56]; Krewer et al 2014 [57]; Etoh et al 2015 [58]; Ochi et al 2013 [59]; Wu et al 2014 [60]; Yamaguchi et al 2012 [61]; Mills et al 2016 [62]; Santamato et al 2015 [63])Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Botulinum Toxin[edit | edit source]

Weak Recommendation

  1. Botulinum Toxin A in addition to rehabilitation therapy may be used to reduce upper limb spasticity but is unlikely to improve activity or motor function. (Foley et al 2013 [38]; Dashtipour et al 2015 [39]; Baker et al 2015 [40]; Gracies et al 2014 [42])
  2. Botulinum Toxin A in addition to rehabilitation therapy may be useful for improving muscle tone in patients with lower limb spasticity but is unlikely to improve motor function or walking. (Wu et al 2016 [60]; McIntyre et al 2012 [51]; Olvey et al 2010 [52])Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Contracture Management[edit | edit source]

Strong Recommendation AGAINST

  1. For people with stroke at risk of developing contracture, routine use of splints or prolonged positioning of upper or lower limb muscles in a lengthened position (stretch) is not recommended. (Katalinic et al 2010 [64])Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Practice Statement
Consensus-based Recommendations

  1. For stroke survivors, serial casting may be trialled to reduce severe, persistent contracture when conventional therapy has failed.
  2. For stroke survivors at risk of developing contracture or who have developed contracture, active motor training to elicit muscle activity should be provided.

Fatigue Management[edit | edit source]

Fatigue is common complaint post-stroke, and is evident even in those individuals who have made an otherwise complete recovery. Over 40% of long-term stroke survivors report ongoing issues with fatigue which impact on their daily living activities with lack of energy and/or an increased need to rest every day, as the main characteristics which can be brought on by both mental and physical activity. Fatigue has also been associated with depression, and may be a predictor of shorter survival. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Management strategies include the identification of triggers and re-energisers, environmental modifications and lifestyle changes, scheduling and pacing, cognitive strategies to reduce mental effort, and psychological support to address mood, stress and adjustment. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title [36]

Strong Recommendation 

People with stroke who are medically stable but who report fatigue should be offered an assessment for mental and physical factors that may be contributing, particularly when engagement with rehabilitation or quality of life is affected. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Practice Statement
Consensus-based Recommendations

  1. Therapy for stroke survivors with fatigue should be organised for periods of the day when they are most alert.
  2. Information and education about fatigue should be provided to individuals with Stroke and their Families/Carers. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
  3. Potential modifying factors for fatigue should be considered including avoiding sedating drugs and alcohol, screening for sleep- related breathing disorders and depression
  4. While there is insufficient evidence to guide practice, possible interventions could include exercise and improving sleep hygiene Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title



[edit | edit source]

Recent Related Research (from Pubmed)[edit | edit source]

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References[edit | edit source]

References will automatically be added here, see adding references tutorial.

  1. 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 Veerbeek JM, van Wegen E, van Peppen R, van der Wees PJ, Hendriks E, Rietberg M, Kwakkel G. What is the evidence for physical therapy poststroke? A systematic review and meta-analysis. PloS one. 2014 Feb 4;9(2):e87987.
  2. De Jong L.D., Nieuwboer A., & Aufdemkampe, G. (2006). Contracture preventive positioning of the hemiplegic arm in subacute stroke patients: a pilot randomized controlled trial. Clinical Rehabilitation, 20: 656-667.
  3. Ada L., Goddard E., McCully J., & Bampton J. (2005). Thirty minutes of positioning reduces the development of shoulder external rotation contracture after stroke: A randomized controlled trial. Archives of Physical Medicine and Rehabilitation, 86(2): 230-34.
  4. 4.0 4.1 Scottish Intercollegiate Guidelines Network. Management of Patients With Stroke: Rehabilitation, Prevention and Management of Complications, and Discharge Planning: a National Clinical Guideline. (2010)
  5. Clinical Guidelines for Stroke Management A Quick Guide for Physiotherapy. National Stroke Foundation, Australia, 2010.
  6. Veerbeek JM, van Wegen E, van Peppen R, van der Wees PJ, Hendriks E, Rietberg M, Kwakkel G. What is the evidence for physical therapy poststroke? A systematic review and meta-analysis. PloS one. 2014 Feb 4;9(2):e87987.
  7. 7.0 7.1 Cabanas-Valdes R, Cuchi GU & Bagur-Calafat C, 2013. Trunk training exercises approaches for improving trunk performance and functional sitting balance in patients with stroke: a systematic review. Neurorehabilitation, 33, 575-92.
  8. 8.0 8.1 Pollock A, Gray C, Culham E, Durward Brian R, et al, 2014a. Interventions for improving sit-to-stand ability following stroke. Cochrane Database of Systematic Reviews, CD007232.
  9. Bang DH, Cho HS. Effect of body awareness training on balance and walking ability in chronic stroke patients: a randomized controlled trial. Journal of physical therapy science. 2016;28(1):198-201.
  10. 10.0 10.1 van Duijnhoven HJ, Heeren A, Peters MA, Veerbeek JM, Kwakkel G, Geurts AC, Weerdesteyn V. Effects of Exercise Therapy on Balance Capacity in Chronic Stroke. Stroke. 2016 Oct 1;47(10):2603-10.
  11. Stanton R, Ada L, Dean CM, Preston E. Biofeedback improves activities of the lower limb after stroke: a systematic review. Journal of physiotherapy. 2011 Dec 31;57(3):145-55.
  12. Tyson SF &amp; Kent RM, 2013. Effects of an ankle-foot orthosis on balance and walking after stroke: a systematic review and pooled meta-analysis. Archives of Physical Medicine &amp; Rehabilitation, 94, 1377-85.
  13. English C, Hillier SL. Circuit class therapy for improving mobility after stroke. The Cochrane Library. 2010 Jan 1.
  14. Mehrholz J, Pohl M, Elsner B. Treadmill training and body weight support for walking after stroke. The Cochrane Library. 2014 Jan 1.
  15. Corbetta D, Imeri F, Gatti R. Rehabilitation that incorporates virtual reality is more effective than standard rehabilitation for improving walking speed, balance and mobility after stroke: a systematic review. Journal of physiotherapy. 2015 Jul 31;61(3):117-24.
  16. Rodrigues-Baroni JM, Nascimento LR, Ada L, Teixeira-Salmela LF. Walking training associated with virtual reality-based training increases walking speed of individuals with chronic stroke: systematic review with meta-analysis. Brazilian journal of physical therapy. 2014 Dec;18(6):502-12.
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