Other Rehabilitative Issues: Dysphagia/Gait Training/Locked-in Syndrome

Dysphagia management is multidimensional, including emphasis on oral hygiene. Range-of-motion exercises, oral motor strength, and coordination, including lip, tongue, and jaw and respiratory muscles and vocal cord adduction, are performed 5 to 10 times per day. Compensatory strategies include head rotation to the weaker side, tucking the chin while swallowing, and performing dry swallows between boluses of food to reduce aspiration risk. These programs are initiated as soon as the patient is alert enough to understand instructions. Modern stroke therapy protocols emphasize these modalities to prevent aspiration pneumonias that prolong hospitalization, often requiring intensive care stays with increased fatalities.

GAIT DISORDERS

Therapeutic approaches to the patient with gait disorders after a stroke focus initially on proximal muscle stabilization, often using proprioceptive neuromuscular facilitation techniques to regain better distal extremity control. Therapy can use verbal or visual feedback for more symmetric foot placement with a narrower base of support and use a stepwise approach to improve balance and gait stability by working on turns, walking backward, or sideways, step ups and downs, and using progressive external perturbations. Strategies such as using weighted walkers for more external support and use of ankle weights to improve proprioceptive feedback have also been used with some success in patients with ataxic gait.

Gait training should be initiated when the patient has sufficient postural control to maintain an upright stance. Parallel bars and assistance from one or more therapists may be required in the early stages. Ankle foot orthoses (AFO) support paretic muscles and provide stability to the ankle and knee joints of patients with hemiplegia during transfer and gait training. New technologies that allow patients to begin gait training earlier and facilitate motor recovery include partial weight support lower extremity robotic devices and functional electrical stimulation orthoses.

Gait training in those with hemiplegia focuses treatment on the component parts of the gait cycle. The patient initiates gait by weight shifting toward the stronger leg in order to unweight the paretic one. The patient is then instructed to flex the paretic hip, minimizing external rotation and using the inertia of the leg to swing the leg toward a position slightly forward and lateral, ideally making contact at the heel rather than the forefoot. Toe clearance during swing phase of gait and heel strike is usually aided by an orthotic to assist with dorsiflexion. The patient is then told to contract the paretic side quadriceps and gluteals before shifting his or her weight to the paretic side in order to unweight and advance the stronger leg. More advanced hemiparetic gait training focuses on improving the symmetry of gait by working on hip flexion, weight shifting, stance duration, foot placement, and arm swing. However, patients often require other interventions, including pharma-cologic means such as Botox or baclofen (a γ-aminobutyric acid [GABA] agonist), for tone management to significantly impact gait quality.

LOCKED-IN SYNDROME

Patients with locked-in syndrome resulting from basilar thrombosis (see Plate 9-21) benefit from intensive rehabilitation. Although most patients remain locked in, some patients can regain motor function over time, occurring up to a year poststroke. Areas of focus are dysphagia therapy, communication, respiratory function, seating, mobility and, where able, activities of daily living. Augmentative communication devices triggered by sensitive switches or eye tracking systems can allow individuals to communicate, control their environment, and use computer-based entertainment.

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