special subjects
Stroke Rehabilitation
Hemiplegia
For patients with hemiplegia, placing 1 or 2 pillows under the affected arm can prevent dislocation of the shoulder. If the arm is flaccid, a well-constructed sling can prevent the weight of the arm and hand from overstretching the deltoid muscle and subluxating the shoulder. A posterior foot splint applied with the ankle in a 90° position can prevent equinus deformity (talipes equinus) and footdrop. Resistive exercise for hemiplegic extremities may increase spasticity and thus is controversial. However, reeducation and coordination exercises of the affected extremities are added as soon as tolerated, often within 1 week. Active and active-assistive range-of-motion exercises are started shortly afterward to maintain range of motion. Active exercise of the unaffected extremities must be encouraged, as long as it does not cause fatigue. Various activities of daily living (eg, moving in bed, turning, changing position, sitting up) should be practiced. For hemiplegic patients, the most important muscle for ambulation is the unaffected quadriceps. If weak, this muscle must be strengthened to assist the hemiplegic side. A gait abnormality in hemiplegic patients is caused by many factors (eg, muscle weakness, spasticity, distorted body image) and is thus difficult to correct. Also, attempts to correct gait often increase spasticity, may result in muscle fatigue, and may increase the already high risk of falls, which often result in a hip fracture; functional prognosis of hemiplegic patients with a hip fracture is very poor. Consequently, as long as hemiplegic patients can walk safely and comfortably, gait correction should not be tried. Additional treatments for hemiplegia may include the following: Constraint-induced movement therapy:The functional limb is restrained during waking hours, except during specific activities, and patients are forced to do tasks mainly with the affected extremity. Robotic therapy:Robotic devices are used to provide intensive repetition of the therapeutic movement, guide an affected extremity in executing the movement, provide feedback (eg, on a computer screen) for patients, and measure patient progress. Partial weight–supported ambulation:A device (eg, treadmill) that bears part of a patient’s weight is used during ambulation. The amount of weight borne and speed of ambulation can be adjusted. This approach is often used with robotics, which allows patients to contribute to ambulation but provides force as needed for ambulation. Total body vibration:Patients stand on an exercise machine with a platform that vibrates by rapidly shifting weight from one foot to the other. The movement stimulates reflexive muscle contraction. 