MedifocusHealth

• Stretching orthoses for the inhibition of tone, maintenance of muscle fiber length, elongation of shortened tissues by prolonged positioning, and reduction of pain
• Inhibitory orthoses, such as anti-spasticity splints, decrease tone by placing a low-intensity, prolonged duration stretch on appropriate joints to achieve full range of motion.
• Conventional wrist-hand orthoses may be fabricated to preserve the balance between extrinsic and intrinsic musculature, provide joint support, and prevent deformities.
• Daily prolonged stretching exercises
• Weight-bearing exercises

More aggressive interventions may be used to decrease more diffuse spasticity. Appropriate medications for cerebral spasticity include dantrolene (Dantrium), clonidine (Catapres), or tizanidine (Zanaflex). Neurolytic agents, such as phenol or denatured alcohol, may decrease spasticity immediately upon injection, but may cause dysesthesias (distortion of the sense of touch such that an ordinary stimulus can be perceived as painful, or vise versa where a painful stimulus can go unnoticed) or edema in the injected extremity. Botulinum toxin prevents the release of acetylcholine from the nerve terminal and is better tolerated by most patients. Intrathecal baclofen, normally used in patients with traumatic brain or spinal cord injury, may be used in selected stroke survivors without loss of strength in the unaffected limbs. Muscle release or tendon lengthening procedures may be indicated to reverse contractures in conjunction with other interventions.

Falling

Falling is one of the most common complications of stroke. The number of falls while still in the hospital is quite high (up to 22% of patients) and is considered to be a strong predictor of falling after discharge. Second falls tend to occur twice as often as the first fall. Falling is generally associated with the presence of other complications including:

• Increased age
• Right hemisphere strokes
• Male gender
• Visuospatial neglect
• Urinary incontinence
• Medications such as diuretics, antidepressants, or sedatives
• Impaired levels of functioning for activities of daily living
• Postural instability
• Impulsivity

One of the most serious complications of a falling is hip fracture. An important part of any rehabilitation program must include fall prevention strategies such as balance training, exercise, call bells, bed or chair alarms, and other precautionary steps that can be effective in the patient's environment. Patients should be screened to determine who may be at high risk for falling and intensive preventive measures should be taught to both the patient and caregiver. In addition, medications prescribed for the patient should be examined to evaluate side effects of fatigue, imbalance, or lack of coordination. Caregivers should also be trained in fall-prevention and should be guided regarding modifying the home environment for the safety of the patient.

Dysphagia

Swallowing dysfunction, or dysphagia, may occur in up to one-third of patients with cortical or brainstem lesions. It is characterized by impairment of the voluntary control of chewing and moving food around in the mouth, or by difficulty with the actual process of swallowing. Dysphagic patients with hemispheric lesions are usually characterized by weakness of the tongue or lips on the affected side, range of motion, and sensation; delayed pharyngeal swallow; contralateral pharyngeal dysfunction; oral apraxia (inability to make a voluntary muscle movement); auditory comprehension deficits; reduced orientation; perceptual and attention deficits; impulsivity; errors in judgment; and loss of intellectual control over swallowing. Patients with brainstem lesions may exhibit decreases in muscle strength and range of motion; decreased sensation; pharyngeal swallow absence or delay; pharyngeal dysfunction; or unilateral vocal cord paresis.