Subacute Management Following a Basal Ganglia Hemorrhage Using PNF and Lower Extremity

Strengthening in Combination with Best Physical Therapy Practices

Jocelyn Braun
Advisor: Karen E.H. Grossnickle
Doctoral Program in Physical Therapy, Central Michigan University

Background & Purpose Timeline for Episode of Care Outcomes

- Strokes affect 795,000 people each year in United States - Met the minimal detectable change of the FIST and the
- Hemorrhagic stroke occurs when there is a bursting of a PASS from the time of reexamination to the last day of
blood vessel in the brain treatment
- Basal ganglia is a common location for hemorrhagic - Improvements in functional mobility
strokes with resulting impairments in movement disorders - Less cuing needed and patient demonstrated better motor
due to the basal ganglia’s role in movement planning
- Disorders are commonly unilateral and will occur on - Improved postural control during transfers and less tactile
contralateral side of body to where damage was sustained and verbal cuing needed
- Physical therapy management commonly includes gait - Completed transfers from bed to and from wheelchair
training, transfer training, bed mobility training without use of assistive device
- Proprioceptive Neuromuscular Facilitation (PNF) and - Gait showed greatest improvements during duration of
lower extremity strengthening exercises have been shown treatment
to be beneficial for patients following a stroke - Able to walk longer distances with only minimum
- Purpose: To determine if PNF and lower extremity assistance for postural control and right step length with
strengthening exercises are beneficial in improving use of platform walker
functional mobility, including transfers and ambulation, - Increased gait speed and quality with no cuing
when used with best physical therapy practices - Able to make turns during ambulation trials
Results - Able to walk short distances with patient taking a right
Case Description step on his own after given tactile and verbal cuing
Test or Measure Initial Examination Reexamination End of Interventions
- 45-year-old male who sustained a basal ganglia
Discussion
hemorrhagic stroke
- Lived independently with no functional limitations prior to Sit to/from Standa Maximum Assist x2 Minimum Assist Minimum Assist - Frequency of lower extremity and PNF exercises may have
stroke
- Referred to subacute rehab due to inability to complete
Therapists played a role in outcomes
transfers or ambulate without assistance - Doing exercises 3 times per week for 30 minutes at each
Supine to/from Sita Maximum Assist x2 Minimum Assist Minimum Assist trial is beneficial in improving mobility
- Stroke had resulted in right-sided hemiparesis, global
aphasia, and dysphagia Therapists - Exercises need to have sufficient frequency, intensity,
- Initial examination and reexamination findings can be and duration
found in the table under “Results” Transfer Bed to/from Maximum Assist x2 Minimum Assist with Stand Pivot Transfer - PNF exercises were only done during 5 sessions
- Outcome Measures: Function in Sitting Test (FIST) and Wheelchair Therapists use of Slideboard with Minimum Assist - Frequency and intensity of gait and transfer training could
Postural Assessment Scale for Stroke (PASS) have also been increased
Ambulation a Unable to Attempt 8 feet in parallel bars 40 feet with TRAMb - Use gait training devices, such as the TRAM, more
frequently
Interventions with use of left arm for with patient able to take - Body weight supported over ground training and body
support and minimum right step on his own weight supported treadmill training has been found to
⁻ Gait training using parallel bars, platform walker, hemi- assistance for trunk with cuing, 70 feet with improve gait outcomes
walker, and TRAM. Cuing and assistance for trunk support - Attitude and motivation may have played a role in
and for right swing phase. Increased distances and control and moderate to platform walker and outcomes as this was a common limitation in the amount of
decreased amount of support given. Added turns. maximum assistance for minimum assistance for practice that was able to be done
⁻ Transfer and bed mobility training with and without - Depression and anxiety are common diagnoses after
assistive device, caregiver education to nursing staff
right step right step and minimum stroke and have been associated with less desirable
⁻ PNF: rhythmic initiation and alternating isotonics for the assist for trunk control outcomes
right lower extremity in and out of flexion and extension, - Patient showed signs and symptoms of these diagnoses
Function in Sitting Test 29/56 45/56 54/56 - Encouragement, imagery, and targets were useful strategies
moderate resistance given, pelvic anterior elevation and
posterior depression that were used during gait training
⁻ Lower extremity strengthening: mini squats, step-ups with - Appropriate discharge locations for patients following acute
the right leg onto varying surfaces, hip abduction and
Postural Assessment 8/36 23/36 27/36 care stay
adduction with manual resistance Scale for Stroke - Patient was appropriate for subacute rehabilitation
⁻ Neuromuscular Re-education: single leg stance on right aFIM
- Factors to consider for discharge from acute care:
leg, reaching in midline and outside base of support in = Functional Independence Measure: Levels of Assistance: dependent= patient performs <25% of effort, maximum assistance= patient performs patient’s abilities and tolerance for therapy, patient’s
25-50% of effort, moderate assistance= patient performs 50-75% of effort, minimal assistance= patient performs 75% or more of effort, supervision or wants and needs, support patient has available
varying directions, static standing with no support, weight
standby assistance= cueing required or setting up items for use, independent= patient performs 100% of effort safely and without cueing
shifting b TRAM, Community Products, LLC, Rifton, NY

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