ASSESSMENT OF LIMBS IN THE STROKE PATIENTS
Stroke is the leading cause of disability in adults in the world, stroke is a brain attack similar to a heart attack, and is mostly caused by a blockage of a blood vessel to part of the brain, the beta cell is the most abundant cell in the cerebral cortex,it is responsible for the function of upper limb, during stroke attacks its get damaged and cause improper function of the upper limb, the symptoms of the stroke occurs in the order of weakness of Face, weakness of Arms, impaired Speech, loss of vision, loss of consciousness. since the weakness of arms affects the day to day activities and the quality of life which make even harder for the affected persons, this article going to discuss the assessment method used for the improvement of the upper limb functions.
Movement training on an upper limb in stroke patients:
Encouraging the use of the hemiplegic limb through activities helps in the recovery of the limb functions, currently, there is a greater incidence of rehabilitation – induced recovery of the motor function on stroke patients. The motor cortex function in patient with chronic impairment can be altered by the motor activity of the individual.
The method usually followed in earlier period was unilateral movement training from Recent advance studies suggest there are few alternative approach called as bilateral movement training ,in which both the intact and the impaired limb are used ,using of the bilateral limbs promotes the the functional recovery of the impaired limb, the use of the limb should be in a symmetrical movements it allows the brain intact hemisphere to facilitate the activation of the impaired hemisphere, which leads to improvement of upper limb function of the impaired limb by promoting neural plasticity. The study also compared unilateral and bilateral movements, neurophysiological and behavioral changes, the study was done with 12 patients and six of them are given unilateral exercise of the affected limb and six of them were given bilateral exercise of both the intact and the affected limb,
kinematic measurement of upper limb movements were done, functional assessment of the impaired limb was made through the transcranial magnetic stimulation and found that there of improvement in the affected limb after the bilateral exercise of both the affected and the intact limb. the neurophysiological assessment was also done with the help of the transcranial magnetic stimulation they found that there were no changes in the CoG of the EDC muscle representation in either the non-affected or affected hemisphere as a result of movement training. And they found that in some patient there was associated with a change in the cortical representation of a target muscle in the non affected hemisphere individual receiving bilateral training showed a reduction in the movement of time in the impaired limb and there was increased upper limb functional ability found compared to the individual who received unilateral movement trainings. It clearly states that use of bilateral movement training exercise in the stroke patients will be effective than the unilateral exercise.
Use of myoelectric activity in post-stroke patients:
The use of Myoelectric activity from hemiparetic muscles is then used for continuous control of functional electrical stimulation (CFS) of same or synergic muscles to promote restoration of movements during task-oriented therapy (TOT)For recovering of the upper limb function after stroke, particularly in the subacute phase the myoelectric activity will be the safe adjust for rehabilitation.
Scapular Stabilization Exercise on Upper Limb Function:
The study on scapular stabilization in the paretic side and gait ability of hemiplegic patients after stroke remained unclear, so the study was conducted for scapular stabilization in the stroke patients, they selected a total of 17 patients with 9 as scapular stabilization exercise and 8 as control group with simple scapular exercise The scapular stabilization exercise is done in the way maximum shoulder external rotation at 45°, abduction in the supine position and gradually extended as long as till there is no pain. Then, stretching was performed at 90° of the shoulder in a sitting position and gradually extended as long as there was no pain. Finally, the subjects reached toward the ground with their palms, with the shoulder and elbow extension in the sitting position, gradually extending their reach as long as there was no pain. Briefly, participants received 30 min of strengthening exercise on scapular stabilization in the supine and sitting posture. The exercise was conducted 3 times per weeks for a total of 8 weeks. Participants in the control group (simple scapular exercise) received 30 min of shoulder movement exercise (flexion, extension, abduction, adduction, internal rotation, and external rotation) in the supine and sitting posture. And finally, they found that when the patients affected with stroke does scapular stabilizing exercise in the standing position on the paretic side(paralyzed side) for 8 weeks had improvement on their upper limb function and in their gait ability.
Robotic assistance in stroke patients:
A retrospective study was conducted at Les Trois Soleils” Center, Boisisse-Le-Roi, France. They used a end-effector robotic system equipped with 2 translational degrees of freedom emphasizing shoulder and elbow movements from supported hand displacement in the horizontal plan, the use of the robotic device in the spastic paralysed helps in the improvement of physical function, number of controlled clinical trials have suggested positive effects of robotic assisted training programs, intensive 3-month upper limb rehabilitation program combining robot-assisted shoulder-elbow training and conventional rehabilitation care initiated two months following stroke in patients with severe residual motor deficit, range of motion and velocity improved before movement accuracy, An intensive rehabilitation program combining robot-assisted shoulder/elbow training and conventional occupational therapy was associated with improvement in shoulder and elbow movements first, which suggests focal behavior-related brain plasticity. Findings also suggested that recovery of movement quantity related parameters (range of motion, velocity, and smoothness) might precede that of movement quality (accuracy).
If a 3-month upper limb rehabilitation program(robot-assisted and convention rehabilitation) was assisted the improvement was more. which in turn also resulted in an active range of motion and velocity, improved before movement accuracy. This improves that extensive rehabilitation every day may stimulate brain plasticity because elasticity is depended upon movement quantity and movement quality.
Since stoke is one of the commonest conditions which affects the upper limb most of the above assessment can be carried out for the better quality of life in the stroke patients, avoid the risk factors associated with it such as smoking, alcohol, high cholesterol. Future studies can also be done with large number yogic exercise and their benefits in the quality of movement in the upper limb, and prevention is better than cure, so further studies like meditation practice helps in the prevention of stroke can be done. since meditation reduces hypertension and hypertension is the major risk factor for stroke.
GLASGOW COMA SCALE
It was published in the year of 1974 by Graham Teasdale and Bryan J.jennet(professor of neurosurgery at the University of Glasgow Institute of neurological science in the city’s southern general hospital).
GLASGOW COMA SCALE USED IN DEPARTMENTS LIKE:
· It was initially used to assess the level of consciousness after head injury or traumatic accident.
· It is most important assessment method in the department of emergency medicine to assess the level of consciousness.
· It is used in the medicine department for the stroke patients to assess their level of consciousness (it’s most widely used nowadays)
· It is also used for diagnosing and treating patient with physiotherapy exercises, for the particular arms.
ASSESSMENT CHART USED FOR MEASURING COMA SCALE IS
ORIENTED TO TIME, PLACE, PERSON
MOVES TO LOCALIZED PAIN
FLEXION FROM WITHDRAWAL FROM PAIN
ABNORMAL FLEXION(DECORTICATE) ABNORMAL EXTENSION(DECEREBRATE)
8 0R LESS
The prognostic value of the components of the Glasgow Coma Scale following acute stroke
The stroke is the life-threatening medical condition that occurs when the blood supply to the brain has been blocked; Stroke is the second most common cause of death in the world and the most frequent cause of permanent disability. It is the most common problem in the old age people and it also manifests as the medical emergency. For diagnosing and treating the patient with stroke, Glasgow coma scale(GCS) plays an important role. The GCS was initially developed to grade patients suffering from acute traumatic brain injury but later its use was extended to evaluate cerebral dysfunction in many fields of critical care or emergency medicine The patient is selected in the presence or absence of coma stage, a stroke may cause localized motor, speech or language deficits, the accuracy of measuring conscious level can be missed, so sometimes the prognostic value of it can be impaired . Conversely, in patients with a language disorder, the verbal score may reflect stroke severity in addition to its measurement of consciousness level, and for that reason, it may retain useful prognostic information. The total GCS score predicted acute mortality with 88% accuracy, and the verbal component could be excluded from the total GCS score without loss of predictive value.
Comparision of Glasgow scale and Apache II Score for Stroke Patients:
APACHE II (Acute Physiology And Chronic Health Evaluation II) it is a severity-of-disease classification system it’s like one of the several ICU(intensive care unit) scoring system. It is applied within 24 hours of admission of a patient to the ICU and in this, the integer score is from 0 to 71.The score is computed based on several measurements; as the score increase, the severity of the disease increase and the patient will have higher incidence death. The first APACHE model was presented by Knaus in 1981.Measurement of the severity of illness has become a vital component of healthcare research over the past decade1 – 3 for its potential value in assessing the quality of care. For real-time use, accurate prognostic assessment may assist clinical management and counseling of patients and their families, the study performed by HCFA and the Health Data Institute, a severity-of-illness measure based on the APACHE II system, However, the Glasgow Coma Scale, because of its relative simplicity of measurement and abstraction, may be preferable to the APACHE II system as a severity-of-illness measure if the former demonstrates comparable accuracy. So the study compared the accuracy of the APACHE II system with that of the Glasgow Coma Scale for patients hospitalized with a stroke. The study was performed at Cedars-Sinai Medical Center, a 1,100-bed community teaching hospital serving West Los Angeles. The Glasgow Coma Scale has fared well in predicting the outcome for patients with intracerebral hemorrhage, although its accuracy in predicting the outcome for patients with hemorrhagic stroke is uncertain. We suggest that the Glasgow Coma Scale is a useful severity-of-illness measure for stroke patients, including those without intracerebral hemorrhage (93% of our study patients) and may be used instead of the APACHE II system for that purpose. In fact, the APACHE II score added no additional predictive information to that provided by the Glasgow Coma Scale score. For measuring neurological disturbances SAPS and APACHE Scores use the Glasgow Coma Scale (GCS).The GCS-Score was shown as an independent predictor of mortality for acute stroke patients in several studies and it seems to be equal in this regard to APACHE-II Scores. Initial Glasgow Coma Scale Score also Predicts Outcome Following Thrombolysis for Posterior Circulation Stroke
Thrombolytic therapy and Glasgow coma scale:
Thrombolytic therapy for posterior circulation stroke may be beneficial when initiated after 8 hours of symptom onset. Level of consciousness, as measured by Glasgow Coma Scale score, seems to be a more important predictor of outcome than the initial. Nine patients received intravenous therapy; 12 patients received intra-arterial therapy. The median Glasgow Coma Scale score was 9 (range, 3-15). Twelve patients were treated within 8 hours of symptom onset. The initial Glasgow Coma Scale score and treatment within 8 hours of symptom onset were each associated with good outcome. The Glasgow coma scale lays a major role in the thrombolytic therapies.
Since Glasgow Coma Scale used in all the departments nowadays, for assessing the condition of patients, further studies can be conducted like a pre-operative assessment of a patient with Glasgow Coma Scale prevent patient from on table complication.