Stroke Rehabilitation- Sensory, motor, tone, strength balance training.

 Rehabilitation starts as soon as the patient becomes medically stable

Strategies to improve sensory function:-

• The greater the patient is encouraged to use the affected side, the more the chances of increased awareness &function.
• Sensory stimulation is important for recovery. 
• Sensory stimuli stimulates tactile, mechano and muscle receptors for example:- Stroking, Stretch, Superficial &deep pressure and approximation can be used. 
• Upper extremity tasks include:- Stroking hand with different textured fabric, pressing objects on the hand (coin, button, key) for drawing shapes/letters/numbers on the skin. 
• During Stimulation, the patients attention by providing visual,tactile &proprioceptive stimuli on the more affected side (stroking,icing, brushing,Vibrating the Hemiperetic limb) . 
• Teach active visual scanning movements through turning of the head & axial trunk rotation to the more involved side. 
• Cueing(visual, verbal &motor cues) is used to direct patient s attention. Eg:- A red anchor line can be tapped on the floor and the patient directed to visually follow the line from one side to the other. 
• During therapy, the therapist stimulates & encourage voluntary movements of the Hemiperetic limbs while encouraging patient to look at his or her limb while moving. 
• Functional activities that encourage bilateral interaction should be encouraged Eg:- Pouring a drink & drinking from a cup. 

Rom/Oedema prevention/ to improve motor function:-

• Rom exercises are initiated early to maintain joint integrity & mobility & prevent contractures. 
• Active ROM & passive ROM with terminal stretch should be performed daily in all motions. 
• Oedema may develop with the loss of voluntary movement and inactivity. 
• In addition to ROM exercises, elevation, massage, icing or compression, wrapping may be necessary to prevent oedema. 
• Self ROM techniques should be instituted early Eg:- affected extremity is supported &lifted with the help of unaffected extremity, table top polishing exercises to the affected limb, Sitting hands clasped together, reaching to the floor. 

Strategies for tone reduction:-

• Strong Spasticity is typically seen during the middle phases of recovery, it can be inhibited through prolonged pressure &weight bearing Eg:- spasticity in Quadriceps is inhibited through prolonged pressure & weight bearing in kneeling 
• Technique to reduce tone include elongation of spastic muscles through ROM and positioning. 
• The technique of rhythmic rotation combined with axial trunk rotation would promote a reduction in truncal tone. 
• Local facilitation technique ( muscle tapping, Vibration) can be applied to activate antagonists & may prove successful in further reducing spasticity. 
• Modalities & splinting can be effective in reducing tone. 
• Inflatable pressure splints (air splints) stabilize and maintain an extremity in elongated position & provide tone inhibition. 

Strategies to improve strength:- 

• Muscle weakness is the major impairment following stroke. 
• Exercise modalities for strengthening include free weights, elastic bands and machine (PRE, isokinetics  
• Patients with less than 3/5 muscle power, gravity eliminated exercises using power boards, sling suspension or aquatic exercises are indicated. 
• Patients with 3/5 strength, gravity resisted active movements are indicated. 
• Patients with adequate strength are progressed to exercise using added resistance. Eg:- Stair climbing while patient is wearing weighted ankle cuff. 
• Pati with unstable BP, exercise are contraindicated. 

Balance Strategies:-

• Once the postural alignment & static stability is achieved in upright postures, the patient is ready for COM control training. 
• In sitting or standing, the patient is instructed to explore his/ her limits of stability through low frequency weight shifting. 
• The patient learns how far in one direction he/ She can move safely & how to align COM within the BOS to maintain upright stability. 
• The therapist need to stress on symmetrical weight bearing as well as activities that promote the shifting towards the more affected side. 

1. Base of support:- Sitting lower extremities uncrossed to crossed, Standing wide to narrow to tanden position, standing on one lower extremities. 
2. Support surface:- Sitting on a mat to a therapy ball Standing on the floor to standing on dance foam
3. Sensory inputs:- Eyes closed to eyes open
4. Upper extremity position/ support:- weight on one hand& raise the other upper extremity, UE movement- Single UE raise -->Bilateral UE raise, reaching picking up objects from table, floor etc. 
5. LE movement s - Single LE raise, Stepping, Marching in place, moving ball. 
6. Trunk movements - Head & trunk rotation, looking up at ceiling or down to floor
7. Destabilising functional activities & Dual task training.