Superintendent Physiotherapist, Passmore Edwards Medical Rehabilitation Centre

Contractures must not be allowed to occur, the and leg must be supported in a functional position, i.e., the shoulder girdle must not become retracted, nor the shoulder joint stressed whilst moving the patient. Contracture of the flexors and outward rotators of the hip together with the knee flexors and plantar flexors of the foot must be prevented, and a balanced position of the trunk must be maintained. All joints and muscle groups must be put through a full range of movement, with the patient’s active assistance as soon as possible, and he must be taught how to move in bed and to reposition himself. Any measure of independence he can be given at this stage is of immense value-learning to feed himself with a Nelson knife, reaching things from his locker which should, therefore, be on his good side. Exercises used should have the emphasis on body symmetry to reinforce sensory and motor stimulation, and this must be carried through into learning to turn in bed, sit over the edge, standing, rolling, crawling and walking. If this is neglected at this stage, the patient’s instinctive mistrust of his weak side will lead to neglect and failure to make use of what recovery may occur.


HE average number of people suffering from first



strokes is

probably just under 2 per 1,000 of popu~ per year, according to the Report of the Geriatrics Committee Working Group on Strokes, and about half of these will survive to require rehabilitation. Of the remainder, 40 per cent will have no disability, 15 per cent slight disability only, 15 per cent will walk unaided but require some help with self-care activities, 15 per cent will be unable to walk alone, and the remainder will need constant care. Physiotherapists are concerned in helping the hemiplegic patient make full use of his returning function. Where the brain damage is more severe, whilst encouraging the maximum possible use of the affected side, emphasis has also to be placed on the compensatory function of the non-affected side. PATTERN OF RECOVERY THE PATTERN of recovery can be very misleading for the patient, for physical improvement can continue for two years or more, and this, combined with natural optimism makes it hard for many of them to accept any alternative to complete recovery. However, statistics unfortunately prove otherwise, and it is now generally accepted that unless the cause is embolic, it is possible to estimate within 6-8 weeks of onset the degree of useful function which will be attained eventually. If by the end of that time, no voluntary control of the hand is present, then it is unlikely that person will regain a good, func-


and most difficult phase of treatment when it becomes apparent that some limiting disability will persist, and the transitional stage, when the emphasis needs to swing away from working towards full recovery, towards adapting to make the best of a limitation is a difficult one for both therapist and patient, particularly as it has to be explained that some improvement will continue to take place. The therapist must continue to work with the patient on this improvement, yet if he is to be helped to gain maximum independence, he has also to learn to compensate for the deficiencies of his affected side by adapting and using the other side.

future extent of the lesion becomes apparent, and into the secondary stage; when the limits of recovery have begun to be defined.

THE EARLY treatment begins whilst the patient is still in bed, with careful positioning and frequent changes of



tioning arm, sufficient to become naturally two-handed again. Fortunately, the leg requires a lesser degree of recovery to permit adequate walking, unless there is severe sensory loss, and the majority of hemiplegic patients are able to regain a reasonable degree of mobility. The physiotherapist, therefore, needs to vary her approach to treatment; into the early stage, before the






DURING THE past 15 years, at Passmore Edwards Rehabilitation Centre, Clacton-on-Sea, under the medical direction of Dr. J. B. Millard, out of a total of over 8,000 - patients, more than 2,000 have presented with hemiplegia due to C.V.A. Thus an ample opportunity has been afforded to study the effects of an intensive rehabilitation

285 programme upon these patients. The duration of disability on admission of 1,318 patients, based over a 5-year period is as follows:

We appreciate that these patients form a selected group, as the basic minimum criteria for admission is that the patient should be able to be out of bed all day, albeit in a wheel-chair, and be able to be cared for by one person. Most of the patients were admitted direct from hospital, and the average age was 55, ranging from under 20, to over 70. The division of L. and R. hemiplegics was almost equal, and the average stay in the unit was 6 weeks. The treatment is given on a daily basis, from 9-5, Monday-Friday, and the patient’s programme is formulated, following the doctor’s initial assessment, in discussion with the superintendent physiotherapist, head occupational therapist, speech therapist and social worker. The progress of each patient is reviewed at weekly staff meetings, and he is seen each week by the doctor. As his abilities become stabilised, plans for the future are made, and a weekly conference is held with the D.R.O., to help those patients who have a potential for returning to work. As the range of disability is widespread, the treatment programme is based upon groups of varying standards and whilst individual treatment is available, we use it far less than group work at this stage. The stimulation gained by working with other people with similar problems helps the patient to feel less alone, they learn a great deal from each other, and encourage each other

enormously. The groups are divided nominally into ’arm’ and ‘leg’, but obviously there must be an overlap of treatment so that the patient is treated as a whole person, and so that there is the same consistent approach between all therapists, physio, O.T., and speech therapist. The arm groups are divided into three, the first being for patients with little or no voluntary control in the affected arm. The aims for this group will be to teach them to regain and maintain mobility of the affected arm, with self-help exercises, to improve manual dexterity of the unaffected side, and to encourage what control may become available in the affected arm, in that order. The second group is for patients with sufficient return of potential function to warrant the emphasis being on active movement of the affected side, together with passive maintenance work, to encourage the use of the affected arm for supportive work and gross holding, and again to increase dexterity of the unaffected arm for the finer movements. The third group will have a useful degree of functional return, so skilled co-ordination work, stereotactic recognition and two-handed activities are used to encourage as near normal function as possible. The leg groups are similarily divided, and the earliest group will consist of patients with gross leg weakness, spasticity or sensory defects, who require the help of one person to walk, either with physical help or by ’talking through.’ A combination of speech defect, comprehension loss, parietal lobe defects or arm dysfunction may also be present-and this indeed applies to all the groups. This group will need to learn basic standing balance, wheel-chair transfers and management for ease of home

care, progressing to independent walking and stair climbing if possible. The second leg group will be able to walk independently with a walking aid, over a limited distance, and the aim will be to improve gait and mobility through mat work, balance and co-ordination exercises, so that they can manage stairs with their aid, carry something whilst walking, walk outside and cross roads on their own.

The third group would concentrate on finer co-ordination work, progress to walking without an aid, be secure on rough ground and in all weathers, manage public transport, and generally achieve a high degree of mobi-

lity. As the treatment sessions last from 60-75 minutes, time is available for each patient to get out and put away his own equipment, take off and replace his shoes, etc., and generally become so thoroughly accustomed to fending for himself that he will automatically continue when he returns home. This is very important where the family is inclined to be over-protective. All the work must aim at creating an atmosphere of enjoyment and mental stimulation, for a long period spent in a hospital atmosphere can so easily add to the apathy and mental slowness already forced upon many by the cerebral vascular damage. At all times the patient is encouraged to appreciate that the person best able to help him is himself. All therapists must be very aware of how much mental and physical support she is giving, and be prepared to clearly withdraw that support at the earliest possible opportunity. The use of splints for the hemiplegic patient is controversial, but I believe if a patient’s walking is unsafe, because of poor ankle control and instability, or unsightly, then a below-knee caliper is given provided it corrects the defect sufficiently, and the patient should be able to put it on unaided. Often it only need be used as a retra~ing device, although some people will need a caliper as a permanency, so it must not be unnecessarily limiting in movement. The caliper we favour allows full plantar and dorsiflexion but controls in- and eversion. An easily adjustable spring allows for accurate assistance of dorsiflexion and a T-strap can be added to control severe inversion problems. The box-slot can be fitted by a local shoe-repairer into a pair of well-fitting leather heeled and soled lace-up shoes, and is ready for the patient to wear in 2-3 days. Long leg calipers are not advisable, they are so difficult to manage, that if a patient can learn to walk with it, invariably he can learn to walk without it. Added to which, there is a real danger of a fall causing a fracture above the level of the caliper bucket. Should some support be required, a plaster back slab, bandaged on, with a temporary foot-raising device, is all that is needed to train the patient to have confidence in the weight-bearing ability of his leg, and even this should be discarded as soon as possible. Many orthotic devices have been tried in an effort to give the hemiplegic patient a functional hand, but unless there is good voluntary antigravity control present in the shoulder and elbow, they have been found to be of very little value, and are usually rejected for cosmetic reasons. Tenodesis flexor hinge splints do have a place as retraining devices following corrective surgery, but unless a functional hand has been created, the patient will invariably return to being one-handed. A supportive arm sling may be given, if shoulder girdle weakness and a painful shoulder is hindering progress, but should be removed for daily exercises and for gradually increasing periods throughout the day, to prevent contractures and rejection of the arm. It has also to be remembered that some patients are unable to


286 tolerate a sling because the unnatural upsets their walking balance.



GENERAL OBSERVATIONS SEVERAL INTERESTING factors have been brought to notice whilst observing the responses of the patients to the programme-first, the surprisingly high degree of exercise tolerance they are able to accept, and even the hypertensive patient can work up to a full day, and as mobility improves, the hypertension tends to decrease. This ability to maintain full day activity is most important if they are to return to a work situation. Secondly, we have noticed how few patients have been given any simple explanation prior to coming to us. It is vital that those who can comprehend, understand the reasons behind the decisions, for the maximum amount of benefit will only be achieved, if the patient and therapists are working towards the same realistic goal. Leading on from this, all members of the treatment team must present a consistent approach to each patient, the same aims must be clearly evident throughout. This is especially so for those who are worried and confused by their disability, and who are having to come to terms with an unknown future. Thirdly, it used to be accepted that the patient with a R. hemiplegia and a severe speech defect had the greatest problem to surmount. But this is not always so-a L. hemiplegic with moderate or severe parietal lobe defect leading to problems of spacial orientation is less likely our

to become

safely mobile or socially independent than a R. hemi with similar physical problems. The reason appears to be that he is unable to learn to adjust to the new circumstances-the physiotherapist will find he has difficulty in learning new gait patterns and remembering instructions related to his disability. If he has a hemianopia, he will tend to walk into obstacles, or sit on half a chair, because he cannot learn to compensate for it. Often he is unaware of his mistakes or will try to explain it away with an un-related excuse. Because they can verbalize well, and do not give a realistic picture of their abilities, we have collected a few simple tests, which highlight this problem. The greatest difficulty is to produce a satisfactory method of helping them over these

problems. In conclusion. these few slides show the results we have obtained on this group of patients by a full, active programme aiming at maximal independence. Much as we, as physiotherapists, endeavour to improve the physical abilities of stroke patients, so that they regain as great a degree of fitness as possible, unfortunately, there will always be a large percentage who will be reliant upon community resources, and we have found that the facilities for sheltered workshops and day centres are very variable in different areas. There is a very great need for these follow-up services to be improved if stroke sufferers are to return to the





Nutritionist, Avon Area Health Authority (Teaching)

IN 1967 it was suggested that &dquo;the centre of gravity of t health effort lies not in the hospital but in the which presents such interesting and


challenging problems&dquo;’. Even earlier than this Dr. C. F. Brockington, when addressing the Sixteenth English Meeting of the Nutrition Society in 1946, made a strong plea &dquo;that the Health Departments of all major local authorities should have on an experienced dietitian&dquo; 2. Yet before the reorganization of the National Health Service in 1974, of the 156 employing authorities in England only 11had paid heed to Brockington’s plea, although the scope and

their staffs

needs for nutrition education in all branches of the community are so vast. Now the integrated Health Service has been established and an opportunity provided, it is hoped that members of the dietetic profession will prove themselves able to meet the formidable challenge. The subject of this paper is one facet only and it alone could fully and usefully occupy any dietitian working in the community. Theoretically, if the ever-present problem of obesity could be but partially solved, the

workload of G.P.s would be considerably lightened and the general health of the community, presumably, raised. In the Department of Health and Social Security’s Report Diet and Coronary Heart Disease, the panel agree that &dquo;recognisable overweight, including obesity, increases the risk both of ischaemic heart disease and other morbid conditions&dquo;3 and it is further stated that &dquo;There is evidence that a substantial reduction of the body weight of overweight people is alone suflicient to diminish the greater death rate usually associated with

obesity&dquo;4. Until recently

the Health Service has not identified

Group situation in the treatment of obesity and a system of individual referral only has failed dismally with so many people. It has been left to such organizations as ’Weight Watchers’ and others to claim that they have a high success rate through offering the moral support of ’the group’. Group therapy obesity classes have for the past three years become an integral part of this Authority’s (previously City and County of Bristol Department of Health with the

Post-stroke rehabilitation.

284 Return to Fitness (a) POST-STROKE REHABILITATION ELIZABETH A. BULLOCK, M.C.S.P., D.PHYS.ED. Superintendent Physiotherapist, Passmore Edwards Me...
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