314 Medico-legal Update, April-June 2020, Vol. 20, No.

Study on Various Evidences of Physiotherapy Interventions for

Decision Making towards Management of Stroke

Suraj B. Kanase

Associate Professor, Department of Neurosciences, Krishna College of Physiotherapy,

Krishna Institute of Medical Sciences Deemed to be University, Karad

Abstract
Stroke rehabilitation focuses on reducing impairments and functional disability. Regaining functional
independence in stroke patients in order to participate in usual self-care and daily activities as independently
as possible in the final aim. .For this New treatment approaches to enhance recovery are been tried out
globally. Implementing this requires timely understanding of disease in order to decide right approach.
Clinical decision making for correct assessment strategies will largely influence appropriate treatment
strategies. It is therefore necessary to find out evidences for understanding traditional strategies and learn
newer skills for treatment.

Keywords: Stroke, clinical decision making, evidence based practice, assessment, and management.

Introduction of learning and memory, enhancing neurogenesis,

improving axonal regeneration, facilitating
Stroke is one of the leading cause of death and
neurotransmitters and growth factors which can facilitate
impairments worldwide. The effect on patients, their
the recovery process in subjects with stroke. Following
families and economy are increasing day by day due
stroke, the motor recovery is often inadequate. The site
to the long-term physicaland cognitive consequences
of lesion, stage of recovery, assessment strategies and
of stroke. By 2030,stroke prevalence is expected to
treatment strategies often plays an important role in
increase by 25% in the USA1. Importance is been given
functional outcome. Long term survival can be predicted
on acute care management for stroke due to the nature of
by functional outcome at 6 months4. Many approaches
disease. Significant research is going on management as
are based on the principle of neural plasticity.
per the stage and duration of disease. Although recovery
varies among stroke patients, studies have suggested Effects of stroke: Effect of stroke is decided by
that functional recovery is predictable inthe first days site and initial stroke lesion5. Altered Consciousness/
after stroke2. Advances based on animal models have attention/alertness, Reduced energy/motivation,
sharpened our understanding of the genetic, molecular, Dysphagia, Dysphonia/dysarthria/dysphasia Reduced
physiologic, cellular, and behavioral adaptations that muscle power/tone, Altered sensation/proprioception,
drive and may limitthe recovery of function3. Various Reduced co-ordination, Change in temperament/
therapies are based on changing the mechanisms personality, Executive dysfunction/cognitive decline,
Perceptual change, Loss of visual acuity/field deficit,
Reduced joint stability/mobility, Balance impairment,
Altered gait pattern are common impairments following
Corresponding Author: stroke. Motor impairment is the most commonly
Suraj B. Kanase recognized one5. The focus of management is to achieve
Associate Professor, Department of Neurosciences, voluntary motor control in order to reduce disability
Krishna College of Physiotherapy, Krishna Institute of and promote functional independence. Multiple studies
Medical Sciences Deemed to be University, Karad have assessed novel therapeutic interventions that may
e-mail: drsurajkanase7@rediffmail.com improve both motor and non motor symptoms. It is
 Medico-legal Update, April-June 2020, Vol. 20, No. 2 315
becoming extremely important to assess the effect, the of repetitions and transference of training in variety of
impact despite limitations in clinical practice. In 2001, situations. Regular practice with attention, motivation is
the World Health Organization developed and endorsed effective in enhancing motor control.
the International. Classification of Functioning,
Disability and Health (ICF)6. Animal studies are identifying genetic and
biochemical pathways involved in the establishment
Clinical decision making: Clinical decision making of new anatomic connections and functional network
is a contextual, continuous, and evolving process, where reorganization (e.g., axonal sprouting, dendrite
data are gathered, interpreted, and evaluated in order to proliferation, neurogenesis).11 In same manner a human
select an evidence-based choice of action. brain undergoes continuous anatomical, physiological
changes following stroke.
In the context of the complex and nature of clinical
practice, therapists gathered data that they considered Recently published draft guideline on
meaningful during patient examination. The findings ‘Therehabilitation and support of stroke patients’,
provide insight into factors influencing assessment developedby the UK National Clinical GuidelineCentre
decisions and suggest mechanisms to foster translation and commissioned by the National Institutefor Health and
of research into clinical practice7. Physiotherapists used Clinical Excellence (NICE), containsa comprehensive
a variety of clinical reasoning strategies and considered list of recommendations on interventionsused in stroke
many factors to influence their decision-making in the rehabilitation12.
planning and delivery of physiotherapy post-stroke.
These included the therapist’s clinical experience, Interventions for stroke: Pharmacology in
patient’s presentation and response to therapy, stroke: Pharmacologic therapy for stroke may be
prioritization, organizational constraints and compliance divided into stroke-specific treatment and stroke
with organizational practice8. prevention13. Pharmacologic treatment of a stroke
depends upon whether the stroke is ischemic or
Education in principles of EBP, EBP self-efficacy, hemorrhagic. Pharmacotherapeutic options for primary
a positive attitude towards research, and involvement ischemic stroke are tissue plasminogen activator (tPA)
in research at work may promote research use in and—under defined conditions—antiplatelet agents.
neurological physical therapy practice9. Pharmacotherapeutic treatment for hemorrhagic stroke
is aimed at controlling the patient’s blood pressure and
Stroke rehabilitation: Stroke rehabilitation is intracranial pressure. Amphetamine showed promise
an ongoing process. Goal of stroke rehabilitation is inhighly selected patients for motor gains14.Aspirin is
to help you relearn skills that are lost when a stroke the only oral antiplatelet agent that has been evaluated
affected part of brain. Stroke rehabilitation can help for the treatment of acute ischemic stroke. Aspirin
regain independence and improve your quality of life. therapy (325 mg) should begin within 24 to 48 hours
Multidisciplinary team approach is effective in delivering of an ischemic stroke, but not within 24 hours of
the necessary care. Accurate prognosis of recovery completion of alteplase therapy15. Management of the
after stroke canhelp to decide on the type, duration and patient’s blood pressure also reduces the patient’s risk of
specificgoals of rehabilitation for individual patients. another stroke16.
Urinary incontinence, sex, pre stroke disability and Peculiar therapies for stroke:
dysarthria affected the level of outcome after stroke;
age, dysphasia, and limb deficit also affected the rate of Stem cell therapy: Stem cells can be defined as
recovery10. clonogenic cells that have the capacity to self-renew
and differentiate into multiple cell lineages. After a
Rehabilitation therapies: Various therapies stroke, millions of brain neurons die within minutes.
have been evolved for stroke care. They are largely Research has found that stem cells target the area with
influenced by underlying principles. Nervous system is chemicals that save and rejuvenate that tissue. Optimal
adaptive and has the capacity to reorganize itself. The time for introducing stem cells seems to be between 36
underlying neurons take over the function in the process and 72 hours after the stroke. Cell therapy is emerging
of recovery. Establishment of inter neuronal circuits as a promising new modality for enhancing neurologic
is largely affected by pattern of rehabilitation, amount recovery in ischemic stroke17. Many studies advocate
316 Medico-legal Update, April-June 2020, Vol. 20, No. 2
stem cell transplantation within thefirst 3 days after impaired neurological systems. iii) Establishing new
ischemia for better functionalrecovery18. Cell therapy patterns of activity through external compensatory
promotes re-vascularization and reduces cerebral mechanisms such as personal orthoses or environmental
inflammation after stroke and phase II clinical trials of structuring and support. vi) Enabling persons to adapt
intravenous transplantation of autologous bone-marrow to their cognitive disability, even though it may not be
stemcells have reported safety and tolerability in stroke possible to directly modify or compensate for cognitive
patients19. impairments, in order to improve their overall level of
functioning and quality of life23 .
Transcranial direct current stimulation (tDCS):
Transcranial direct current stimulation (tDCS) is a form Speech impairments: Constraint-induced aphasia
of neuromodulation that uses constant, low direct current therapy(CIAT) was first proposed by Pulvermüller et al.
delivered via electrodes on the head. It can be contrasted as a therapeutic approach that included the principles of
with cranial electrotherapy stimulation, which generally massed practice (3 to 4 hours per day for 10 consecutive
uses alternating current the same way. Transcranial days), shaping (the difficulty of the required verbal
direct current stimulation has enormous clinical potential actions is gradually increased according to the patients’
for use in stroke recovery because of its ease of use, needs) and constraint of compensatory (nonverbal)
noninvasiveness, safety (does not provoke seizures), communication strategies24. Studies of both tDCS
and sham mode (important for controlled clinical trials) and rTMS have resulted in language improvements,
and because of the possibility to combine it with other including receptive and expressive modalities, and may
stimulation or stroke recovery–enhancing method (eg, offer future supplementary approaches to conventional
simultaneous occupational and physical therapy). therapy25, 26 .

Robotic therapy: Many studies have worked Locked in syndrome: Brain-computer interface
on introducing robotic devices in the management of (BCI) is a hardware and software communications
stroke. Robotic technology has developed remarkably in system that permits cerebral activity alone to control
recent years, with faster and more powerful computers computers or external devices. The devices are most
and new computational approaches as well as greater needed for people with locked-in syndrome from
sophistication of electro-mechanical components20. brainstem stroke who are without voluntary control
Robotic assisted therapy has been found to be effective of their limbs. Alterations in the amplitude of the mu
tool in rehabilitating upper limb motor function. Robot- rhythm by thoughts about an action, are recorded with
assisted therapy for stroke rehabilitation is in a dynamic electroencephalography electrodes and interpreted by a
phase of development and has achieved remarkable computer algorithm, allowing patients to select letters
advances. A small study of 18 patients with chronic or words on a computer screen for communication or to
hemiparesis reported that using a roboticdevice coupled search the Web27.
with virtual reality over 4-weeks improved walking
ability in the laboratoryand the community better than Interventions for Mobility:
robot training alone21. Functional Electrical Stimulation: Can be used
Interventions for Impairments: to generate muscle contraction in otherwise paralyzed
limbs to produce functions such as grasping, walking,
Cognitive Impairments: New dementia is seen bladder voiding and standing. FES is a technique that
in 10% of patients after a first stroke and in more than takes advantage of peripheral nerves and muscles left
onethird of patients after recurrent stroke22. Cognitive unaffected bydamage to the central nervous system.
rehabilitation is systematic, functionally oriented service
of therapeutic activities that is, based on assessment and Aerobic exercise trainingby treadmill, over
understanding of the patients brain behavioral deficits. ground walking, or recumbent cycling, can produce
Specific interventions may have various approaches, a conditioning effect and increase walking speed and
which include :i) Reinforcing, strengthening or endurance28. It has been found to be effective in chronic
reestablishing previously learned patterns of behavior. stroke patients who have recovered with significant
ii) Establishing new patterns of cognitive activity motor control29.
through compensatory cognitive mechanisms or Balance training: Task specific training has been
 Medico-legal Update, April-June 2020, Vol. 20, No. 2 317
shown to improve walking performances in post stroke Conflict of Interest: No conflict of interest.
individuals30. Over-ground gait training is an integral
component of standard physical therapies to improve Source of Funding: Krishna institute of medical
dynamic balance and ensure safe ambulation in the home. sciences deemed to be university, Karad.
Functional reeducation from supine lying to standing has Ethical Clearance: From institutional ethical
been found to be effective in achieving central control in committee from KIMSDU, Karad.
turn improves static and dynamic balance.

Strength and fitness: Standard rehabilitative

References
therapies include selective muscle strengthening by 1. Heidenreich PA, Trogdon JG, Khavjou OA, Butler
isometric and isokinetic exercises to improve the power J,Dracup K, Ezekowitz MD, et al. Forecasting
and endurance of affected and unaffected muscle groups. the future ofcardiovascular disease in the United
Sets of moderate resistance exercise with weights or States: a policy statementfrom the American Heart
elastic bands are feasible for most patients. Association. Circulation2011; 123:933–44.
Locomotor training: Body weight-supported 2. Kwakkel G, Kollen B, Linderman E. Understanding
treadmill training (BWSTT) enables supervised, the pattern of functional recovery after stroke:
repetitive, taskrelated practice of walking. Patients with facts and theories. Restor Neurol Neurosci 2004;
limited motor control wear a chest harness connected to 22:281–99.
an overhead lift to reduce the need to fully load a paretic 3. Murphy TH, Corbett D. Plasticity during stroke
leg. The treadmill induces rhythmic stepping, although recovery: from synapse to behaviour. Nat Rev
the paretic leg and trunk often require physicalassistance
Neurosci. 2009 Dec; 10(12):861–872. [PubMed:
by therapists.
19888284]
Recent advances to enhance plasticity: Sensory 4. Slot KB, Berge E, Dorman P, Lewis S, Dennis
stimulation: Sensory stimulation can be given in a M,Sandercock P. Oxfordshire Community Stroke
number of ways, from passive movement tocutaneous Project the International Stroke Trial (UK); Lothian
stimulation with transcutaneous electrical nerve Stroke Register. Impact of functional status at six
stimulation, and even acupuncture.NMES may also months on long term survival in patients with
work in part by enhancing sensory feedback. Mirror ischaemic stroke: prospective cohort studies. BMJ
therapy has been found to improve functional recovery. 2008; 336:376–9.
Transcranial magnetic stimulation: It is still in its 5. Lawrence E, Coshall C, Dundas R, Stewart J, Rudd
theoretical form. Slow rates of repetitive TMS depress AG, Howard R, et al. Estimates of the prevalence
cortical excitability and high rates increase excitability. of acute stroke impairments and disability in a
Trials have been undertaken in depression, Parkinson’s multiethnic population. Stroke 2001; 32:1279–84.
disease, and dystonia.
6. World Health Organization. International
Classification of Functioning, Disability and Health
Conclusion
(ICF). www.who.int/classification/icf/en (19 April
Many of the stroke survivors are left with chronic 2012, date last accessed).
disabilities. Rehabilitation is very important during the
7. Patricia Q McGinnis, Laurita M Hack, Kim Nixon-
initial phase. Early intervention will allow lot of scope
Cave, Susan L Michlovitz, Factors That Influence
in improving functional mobility and independence.
Impairment following stroke has been extensively the Clinical Decision Making of Physical Therapists
researched and newer approaches have come up. Correct in Choosing a Balance Assessment Approach,
timing of assessment and management is the key of Physical Therapy, Volume 89, Issue 3, 1 March
successful outcome. Future of stroke rehabilitation 2009, Pages 233–247, https://doi.org/10.2522/
is promising as well as challenging. There has been ptj.20080131.
exceptional revolution in stroke care from rehabilitation 8. Mark P. McGlinchey & Sally Davenport (2015)
point of view. Exploring the decision-making process in the
delivery of physiotherapy in a stroke unit,
318 Medico-legal Update, April-June 2020, Vol. 20, No. 2
Disability and Rehabilitation, 37:14, 1277-1284, Emerging Paradigmfor Stroke (STEPS) II. Stroke
DOI: 10.3109/09638288.2014.962106 2011;42:825– 829.
9. Salbach, N.M., Guilcher, S.J., Jaglal, S.B. et al. 18. M. Vendrame, J. Cassady, J. Newcomb, etal.
Determinants of research use in clinical decision Stroke. 2004. 35. 2390–95p.
making among physical therapists providing 19. Schabitz WR, Laage R, Vogt G, Koch W, Kollmar
services post-stroke: a cross-sectional study. R, Schwab S, et al. AXIS: a trial of intravenous
Implementation Sci 5, 77 (2010) doi:10.1186/1748- granulocyte colony-stimulating factor in acute
5908-5-77 ischaemic stroke. Stroke 2010; 41:2545–51.
10. Tilling K, Sterne JA, Rudd AG, Glass TA, Wityk RJ, 20. Esquenazi A, Packel A. Robotic-assisted gait
Wolfe CD. A new method for predicting recovery training and restoration. Am J Phys Med Rehabil.
after stroke. Stroke. 2001 Dec 1;32(12):2867-73. 2012;91:S217–S227. quiz S228-231. [PubMed]
11. Krakauer JW, Carmichael ST, Corbett D, [Google Scholar]
Wittenberg GF. Getting neurorehabilitation 21. Mirelman A, Bonato P, Deutsch J. Effects of training
right: what can be learned from animal models? with a robot-virtual reality system compared with a
Neurorehabil Neural Repair. 2012 Oct; 26(8):923– robot alone on the gait of individuals after stroke.
931. [PubMed: 22466792] Stroke 2009; 40:169–74.
12. National Institute for Health and Clinical 22. Pendlebury ST, Rothwell PM. Prevalence,
Excellence. Stroke Rehabilitation: Clinical incidence, and factors associated with pre-stroke
Guideline Draft. http://www.nice.org.uk/ and post-stroke dementia: a systematic review and
nicemedia/live/11950/56129/56129.pdf (20 April meta-analysis. Lancet Neurol 2009; 8:1006–18.
2012, date last accessed).
23. Keith DC, Cynthia D, Kathleen K et al : Evidence-
13. Piechowski-Józwiak B, Bogousslavsky J. Based Cognitive Rehabilitation: Recommendation
Pharmacotherapy of stroke. Eur Neurol Dis. for Clinical Practice. Arch Phys Med Rehabil 2000;
2006;1:52-62 81 : 1596-1615.
14. Schuster C, Maunz G, Lutz K, Kischka U, et al. 24. Pulvermüller F, Roth VM. Communicative aphasia
Dexamphetamine improves upper extremity treatment as a further development of PACE
outcome during rehabilitation after stroke: a pilot therapy. Aphasiology. 1991;5:39–50. [Google
randomized controlled trial. Neurorehabil Neural Scholar]
Repair. 2011 Oct; 25(8):749–755. [PubMed:
25. Fridriksson J, Richardson JD, Baker JM, Rorden
21712481]
C. Transcranial direct current stimulation improves
15. Adams HP Jr, del Zoppo G, Alberts MJ. Guidelines naming reaction time in fluent aphasia: a double-
for the early management of adults with ischemic blind, sham-controlled study. Stroke 2011; 42:819–
stroke: a guideline from the American Heart 21.
Association/American Stroke Association
26. Barwood CH, Murdoch BE, Whelan BM, Lloyd D,
Stroke Council, Clinical Cardiology Council,
Riek S, O’Sullivan JD, et al. Improved language
Cardiovascular Radiology and Intervention
performance subsequent to low-frequencyrTMS
Council, and the Atherosclerotic Peripheral
in patients with chronic non-fluent aphasia post-
Vascular Disease and Quality of Care Outcomes
stroke. Eur J Neurol 2011;18:935–43.
in Research Interdisciplinary Working Groups:
the American Academy of Neurology affirms the 27. Mizuno K, Tsuji T, Takebayashi T, Fujiwara T, et
value of this guideline as an educational tool for al. Prism adaptation therapy enhances rehabilitation
neurologists. Stroke. 2007;38:1655-1711. of stroke patients with unilateral spatial neglect: a
randomized, controlled trial. Neurorehabil Neural
16. Marsh JD, Keyrouz SG. Stroke prevention and
Repair. 2011 Oct; 25(8):711–720. [PubMed:
treatment. J Am Coll Cardiol. 2010;56:683-691.
21700922]
17. Savitz SI, Chopp M, Deans R, Carmichael ST,
28. Brazzelli M, Saunders DH, Greig CA, Mead GE.
Phinney D,Wechsler L. Stem Cell Therapy as an
 Medico-legal Update, April-June 2020, Vol. 20, No. 2 319
Physical fitness training for stroke patients.Cochrane Neurorehabil Neural Repair. 2012 Jan;26(1):85–
Database Syst Rev. 2011 Nov 9.(11):CD003316. 95. [PubMed: 21885867]
[PubMed: 22071806] 30. Kanase SB, Varadharajulu G. Effect of Task
29. Globas C, Becker C, Cerny J, Lam JM, et al. Chronic Related Training versus Conventional Training on
stroke survivors benefit from high-intensity aerobic Walking Performances in Post Stroke Patients. Age
treadmill exercise: a randomized control trial. (years). 2012;54:53-15.