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30 SECONDS OF THERAPY:  Stroke Rehab Tactics

Jan 31

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START: 

  1. AFOs: First address a patient’s foot drop or stance instability by prescribing an Ankle-Foot Orthosis (AFO) to achieve better toe clearance, increase confidence, increase stance stability, promote heel off and conserve energy.

  2. Dynamic Circuit Training: Create circuits to combine strength and endurance exercises with mobility tasks. (Sit-to-stand walk to chair Stand-to-Sit, Sit-to-stand side step Stand-to-Sit, Side Step Step Up Step Down laterally both directions, and short-distance walking drills with resistance bands. 

  3. Rehabilitate All Walking Components: 

    WALKING-SPECIFIC MOTOR CONTROL:  (Hip Flexors: resisted hip flexion exercises in standing, Quadriceps Strengthening: knee extensions, Tibialis Anterior: heel walking drills, Plantarflexors:  Toe Walking, Squats to promote heel off). CARDIORESPIRATORY FITNESS: (Gluteus Maximus and Hamstrings for low-impact endurance training: Lunges, Stairs, Retro Walking, Core Muscles: planks, push ups, pull up bar hanging, Diaphragm controlled breathing exercises: swimming and fast walking to build stamina.) BALANCE AND CONTROL:  (Ankle Stabilizers: Wobble Boards, Air Discs for ankle stability, Hip Abductors: Hip hikes, Side steps,  Paraspinals: Seated forward bends, resisted standing rows for postural control during walking.)

STOP: 

  1. Regressing Programs: Progress exercises until patients fail 3/5 attempts before decreasing intensity or difficulty. Failure encourages adaptation and promotes progress.  

  2. Paretic Limb Isolation: Don’t forget to strengthen both sides. Single leg balance on both limbs, Resisted side-stepping to target the non-paretic hip abductors, catch and throw, heel walks, toe walks. 

  3. Babying Patients: Mimic real-life movements: (climbing stairs, butt scoots, or uneven surfaces.) Standing Exercises are essential to promote endurance and weight acceptance. 

WHY: 

  1. AFOs: Promote foot clearance, increase confidence with ambulating, decrease fall risk, improve stance stability and decrease energy expenditure. AFOs are a tool, not a limitation—encourage patients to see it as part of their progress, they help the patient progress to more complicated exercises where recovery occurs. 

  2. Plantar flexors: Remember plantarflexors primary role in gait is to stop the forward progression of the tibia leading to heel raise and passive knee flexion. This is overlooked and makes forward progression very difficult and unstable. 

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REFERENCES: 0) Jill Seale, PT, PhD, NCS Walking Recovery Post Stroke- continuED 08/12/2020 https://www.physicaltherapy.com/pt-ceus/course/walking-recovery-post-stroke-3789 1. Abbasian S, Rastegar M. Is the intensity or duration of treadmill training important for stroke patients? A meta-analysis. J Stroke Cerebrovasc Dis. 2018; 27: 32-43.

2.Holleran CL, Straube DD, Kinnaird CR et al. Feasibility and potential efficacy of high intensity stepping training in variable contexts in subacute and chronic stroke. Neurorehabil Neural Rep. 2014; 28: 643-51.

3.Hornby TG, Holleran CL, Hennessy PW et al. Variable intensive early walking poststroke (VIEWS): A randomized controlled trial. Neurorehabil Neural Rep. 2016; 30: 440-50.

4.Hornby TG, Reisman DS, Ward IG et al. Clinical Practice Guideline to improve locomotor function following chronic stroke, incomplete spinal cord injury and brain injury. J Neurol Phys Ther. 2020; 44: DOI: 10.1097/NPT.0000000000000303

5.Wiener J, McIntyre A, Janssen S, Chow JT, Batey C, Teasell R. Effectiveness of high-intensity interval training for fitness and mobility post stroke: A systematic review. PM R. 2019; epub ahead of print. Doi: 10.1002/pmrj.12154.

6.Williams G, Hassett L, Clark R, Bryant A, Olver J, Morris ME, Ada L. Improving walking ability in people with neurologic conditions: A theoretical framework for biomechanics-driven exercise prescription. Arch Phys Med Rehabil. 2019; 100: 1184-90.

7.Winstein CJ et al. Guidelines for adult stroke rehabilitation and recovery. A guideline for healthcare professionals from the American Hear Association/American Stroke Association. Stroke. 2016. 47: e98e-169.



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