Interventions of a Persons Poststroke

• Interventions for persons poststroke follow the fundamental principles that you learned in module 3 and are based on ongoing assessment and the plan of care
• Physical therapy


  • Focuses on driving adaptive plasticity to produce long-lasting effects and preventing maladaptive plasticity within the constraints of the recovery processes that occur within the central nervous system after injury
  • Incorporates the principles of experience-dependent plasticity and motor learning strategies to induce and maximize adaptive plasticity
• Interventions are not stroke-specific but physical therapists can integrate the knowledge of the common motor control, postural control, and mobility impairments patients poststroke have into treatment strategies
• Brunnstrom stage


  Stages of motor recovery poststroke
• Limiting use of the paretic limb may result in loss of neural projections in the hand, arm or leg regions of the motor cortex
• Increasing use of the non-paretic arm or leg will result in neuroplastic changes that expand the neuronal networks associated with these body parts
• It is imperative that physical therapy focus on increasing sensorimotor activity in the paretic limbs to preserve the neural networks and/or induce positive neural change within the lesioned hemisphere
• Compensatory strategies


  Used when recovery is not possible
• Task-oriented approach to intervention

  1. Resolve, reduce, or prevent impairments in body structure and function

  2. Develop effective and efficient task-specific strategies for accomplishing functional task goals

  3. Adapt functional goal-oriented strategies to changing task and environmental conditions in order to maximize participation and minimize disablement
• Failure to use the paretic limbs will result in additional neural loss
• Plasticity induced will be specific to the treatment provided
• Plasticity requires high intensity which involves the rate and amount of practice and many repetitions
• Early plasticity may improve or impede subsequent plasticity
• Persons poststroke who suffer complications during the acute and sub-acute stages of recovery tend to have lower functional status a year after their stroke
• Early activity and upright sitting and standing posture can prevent complications such as deep vein thrombosis, pulmonary emboli, pneumonia, skin breakdown, postural hypotension, and falls
• In the acute phase, physical therapy should be mildly exerting, consistent with the Borg scale of less than 12 or fairly light
• Physical therapist must monitor the patient's international normalized ratio, INR, to determine if therapeutic threshold levels of anticoagulants have been reached
• Proper positioning and ROM activities are key in preventing contractures in hypertonic muscle groups
• Hypertonic muscles in the upper extremity

  Scapula retractors, shoulder adductors, internal rotators, and extensors, elbow, wrist, and finger flexors, and forearm pronators
• Hypertonic muscles in the lower extremity

  Hip flexors and adductors, knee flexors, and ankle plantarflexors
• Early intervention


  1. Increasing activation in the paretic limbs using active, active assisted, gravity reduced, and gravity assisted movements

  2. Weight-bearing through the involved limbs to enhance, promote, and stimulate more normal postural alignment, facilitate muscle activation and motor control, and functional extremity use
• Proper positioning and handling of a hypotonic extremity or trunk


  Essential in the management of joint integrity, mobility, and the prevention of contractures
• Positioning in supine


  • Pillow support for UEs in a nonabnormal flexion synergistic position
  • Elevation of limbs to decrease effusion
  • Ankle support by identified system to prevent foot drop
  • Pillow support to prevent ER of Les
  • Head, neck, trunk in midline
• Positioning in sidelying on paretic side

  • Scapular protraction; UE ER, flexion, abduction; elbow extension; wrist neutral; forearm supination
  • LE hip neutral rotation and ABD/adduction, flexion; knee flexion; neutral ankle
• Positioning in sidelying on non-paretic side

  • Scapular protraction; UE ER, flexion, abduction; elbow extension; wrist neutral; forearm supination
  • LE hip neutral rotation and ABD/adduction, flexion; knee flexion; neutral ankle
• Multi-podus boot


  Used for ankle and foot positioning and to prevent skin breakdown on the heel
• Task-oriented practice: bed mobility skills

  1. Bridging

  2. Scooting up/down and side to side

  3. Rolling to side and prone positions and back

  4. Supine to sit, sit to supine
• Key points to working on transfers are to encourage the patient to be an active participant, do not provide any more assistance than is absolutely necessary, and positioning of the extremities in positions that lead into the movement
• Avoid teaching the patient to use the non-paretic limb to slide the paretic limb up during bridging
• The physical therapist should choose key points for hand placement that minimize therapist contact but allow optimal assistance to areas that are most impaired during scooting
• The patient should be doing as much of the work as possible with the physical therapist assisting as little as possible during bed mobility tasks
• Improving steady-state postural control

  Retraining orientation and alignment to help the patient develop an initial position that is appropriate for the task, is efficient or requires minimal muscle activity to maintain vertical alignment in that position and maximizes stability by placing the vertical line of gravity well within the patient's stability limits
• Retraining anticipatory balance control

  Working on movement strategies to control the center of body mass