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A MOTOR RELEARNING PROGRAM FOR STROKE PATIENTS (Back to contents)

By RAMESH MALLADI ZAHEER AHMED SAYEED

PHYSICAL THERAPIST NEUROLOGIST

I NTRODUCTION

Stroke rehabilitation has undergone several changes in the past four decades. The recent change being learning model which is also a couple decades old. This new strategy is based on the basis of the brain's capacity to reorganize itself and its adaptation inspite of an ischaemic insult. Emphasis is laid on the practice of the functional movements that make meaning to the patient.

Motor relearning can be ensured to an optimal level by various means. The factors that control the outcome are numerous. To list a few, manual guidance; demonstration of the desired activity at the normal performance speed; to help the patient in understanding the task, its components and its performance; early initiation of the therapy with active participation of the patient; visualization of the movement components to organize them in the temporal and spatial sequence; visual and verbal feedback.

Besides these factors additional input in the form of weight bearing on the limbs, manual contact, tapping, postures etc. are used to cause stimulation and to elicit the activity of the necessary movement component. The patient is encouraged to "feel the movement" and to recognize the " correct movement response" from incorrect ones so that unnecessary activities can be eliminated. Meticulous evaluation is necessary to design an appropriate rehab protocol.

While organizing a rehab protocol, the learning environment is imperative, which consists of reducing the distracting factors, provision of a comfortable place for the patient with adequate privacy, ensuring consistency of practice, and transference of the learned task into the process of relearning.

Positive reinforcement is yet another factor that plays an important role in directing the patients to recovery. Patient's incorrect response appropriately corrected and on achieving a set target or goal, a reward is given which is most valued and respected. Giving adequate opportunity for the patient to develop problem-solving skills by auto evaluation is more useful than the practice of ready-made solutions.

M ETHOD

More than 1000 cases with ischemic and hemorhagic lesions have been successfully treated. Intra Cranial tumors and cranial trauma were excluded from this series. 220 cases formed the subjects for the present study of Motor Releaming Program in the year 1993 (January- December). Motor Assessment Scale (MAS) was used to measure the functional abilities of the Stroke patient. This scale involves eight parameters of motor function (viz. Supine to side lying, side lying to sitting. Balanced sitting. Sitting to standing etc). The ninth parameter describes general tonus.

Table:1a Infraction

Age Group

Right HP

Left Hp

Total

M

F

M

F

Below 20 yrs.

0

0

0

0

0

21 to 30 yrs.

1

0

0

2

3

31 to 40 yrs.

4

7

4

3

18

41 to 50 yrs.

9

6

7

4

26

51 to 60 yrs.

2

2

14

9

27

Above 61 yrs.

15

13

10

16

54

Total

31

28

35

34

128

Table: 1b Hemorrhage

Age Group

Right HP

Left Hp

Total

M

F

M

F

Below 20 yrs.

0

0

0

0

0

21 to 30 yrs.

0

0

0

0

0

31 to 40 yrs.

4

3

4

1

12

41 to 50 yrs.

7

4

7

3

21

51 to 60 yrs.

13

8

3

4

28

Above 61 yrs.

14

7

5

5

31

Total

38

22

19

13

92

Table:2a Infraction

Age Group

Right HP

Left Hp

Total

M

F

M

F

21 to 30 yrs.

1

0

0

0

1

31 to 40 yrs.

2

3

1

0

6

41 to 50 yrs.

1

2

9

2

14

51 to 60 yrs.

1

1

2

1

5

Above 61 yrs.

3

1

3

2

9

Total

8

7

15

5

35

Table: 2b Hemorrhage

Age Group

Right HP

Left Hp

Total

M

F

M

F

21 to 30 yrs.

0

0

0

0

0

31 to 40 yrs.

0

0

1

0

1

41 to 50 yrs.

3

1

2

2

8

51 to 60 yrs.

1

0

0

2

3

Above 61 yrs.

1

0

1

1

3

Total

5

1

4

5

15

Each parameter is scored on a 7-point scale of 0-6. This scale has been validated for its high inter rater and intra rater reliability (r = 0.87-1.0). MAS scoring was done as soon as the patient was medically stable and satisfied the criteria for scoring, subsequently at the completion of 4,8,16and 24 weeks.

This communication evaluates the data of 50 patients over a period of 24 weeks. During the calendar year of 1993 a total of 220 patients with stroke attended the physical therapy department. Due to a variety of issues only 52 patients were followed up for a 24 week period. Two patients suffered a massive cardiac arrest and passed away at the end of the study period therefore, only 50 patients were included for the study.

Based on the MAS score the patients were classified into five categories.

MAS score >2 or 2 for any one of the seven parameters- Gross functional loss

MAS score between 4 to 6 for any one of the seven parameters- Minimal functional loss

MAS score of 5 and or 6 for any one of the seven parameters- Normal.

Five sub groups were formed,

Group 1 Gross functional loss of upper limb and lower limb formed 4% (2).

Group 2 Minimal functional loss of upper limb and lower limb formed -18% (9).

Group 3 Minimal functional loss in the upper limb and normal lower limb formed 38%.

Group 4 Minimal functional loss in lower limb and normal upper limb formed 0%(0)

Group 5 Near normal function of upper and lower limb formed 40% (20)

Published literature quotes 80% of the patients are independent in ADL and 17% require assistance in bowel and bladder care.

In comparison to that data the Motor relearning program results were quite matching and in some cases superior because patients Group 3 and 5 are independent in ambulation and activities of daily living formed 78% which is far above the published data. Similarly patients with gross functional loss is only 4% which is much less when compared to the published data of 17%.

Enriched environment where the patient find himself or herself following stroke is one of the several important factors. The site, the extent, the nature of lesion, age, sex, the general condition of the patient and last but not the least is the financial implication affects the outcome following stroke.

TABLE - 4

SEX

 

SIDE

MALE

FEMALE

 

Hemiplegia RIGHT

Hemiplegia LEFT

T

R

T

R

 

T

R

T

R

64%

78%

36%

77%

 

12%

81%

58%

75%

32 pts

25 pts

18 pts

14 pts

 

21 pts

17 pts

29 pts

22 pts

   

TYPE

 
   

Infarction

Hemorrhage

 
   

T

R

T

R

 
   

70%

80%

30%

73%

 
   

35 pts

28 pts

15 pts

11 pts

 

Our short experience of 7 years indicates that the stroke rehabilitation team takes due care in organizing an enriched environment for the patient right from the acute phase of stroke. We were able to influence the recovery of the patient rather enable him/her to re-leam the functional activity within relatively a short period and prevent various complications that retard the progress.

CONCLUSION

Stroke rehabilitation has seen several changes in the past four decades. Advent of a learning model is one such event. This principle being adopted and about 50 patients were followed up for a period of 24 weeks. Data analysis reveals that the restoration of functional capacity of the stroke patients based on the principles of learning model are comparatively better than the available published data. The number of the patients considered for the study is relatively less. Perhaps further research and follow up study on significant number of patient population would help us to arrive at positive conclusion.

REFERENCES

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