REHABILITATION OF

NEUROLOGICAL DISORDER
PATIENTS
 Rehabilitation
 Definition of neuro rehabilitaiton
 Principles of rehabilitation
 Goals of rehabilitation
 Types of rehabilitation
 Approach of rehabilitation
 Neurorehabilitation team
 Factors affecting quality of life and coping
 Bobath neurodevelopmetal treatment
approach
 Positioning
 Sitting
 Mobility
 Transfer
 Physical therapy
 Range of motion exercise
 Other exercises
 Treatment of pain and inflammation
 Heat therapy
 Cold therapy
 Electrical stimulation
 Traction
 Massage
 Acupuncture
 biofeedback
 Sensory perceptual deficit
 Communication deficit
 Speech therapy
 Swallowing difficulty
 Bladder dysfunction and retraining
 Neurological disorder and its rehabilitation
 Stroke
 Head injury
 Spinal cord injury
 Parkinsonism
 Gullaine barre syndrome
 Nurses role in rehabilitation
 Summary
 Conclusion
 Rehabilitation is a dynamic process through
which a person is assisted to achieve
optimal physical, emotional, psychological,
social, and vocational potential and to
maintain dignity, self-respect, and a quality
of life that is as self-fulfilling and satisfying
as possible.
 Neurorehabilitation is a complex medical
process which aims to aid recovery from a
nervous system injury, and to minimize
and/or compensate for any functional
alterations resulting from it.
 Rehabilitation should begin during the
intial contact with the patient.
 Restoring the patient to independence or to
regain his/ her preillness
 Maximizing independence within the limits
of the disability.
 Realize goals based on individual patient
assessment and to guide the rehabilitation
program
 Must be an active participation
 Activities of daily living are facilitated.
 Motivate the patient and helps him/her to
attain social independence.
 Physical independence

 Mobility
 Social integration

 Occupational integration
 Psychological support
 Medical rehabilitation :
restoration of structure and
function.

 Vocational
rehabilitation:
 restoration of the capacity
to earn a useful and decent
livelihood
  Social rehabilitation:
restoration of family
and social relationships

 Psychological rehabilitation :
restoration of personal dignity
and confidence
 Institution based : the services are
delivered in an institution for the disabled.
 Outreach based : professional travel to the
community
 Community based :
where resources for
rehabilitation are
available in the
community and
services are delivered
in community area.
 Medical team  Ophthalmologist
 Physiatrist  Paramedical members
 Orthopaedic surgeon  Physiotherapist
 Neurologist  Occupational therapist
 Neurosurgeon  Creative movement
 Plastic surgeon therapist
 Psychiatrist  Recreation therapist
 Paediatrician  Prosthetist
 Obstetrician  Rehabilitation nurse
 Geneticist
 Cardiologist
 Cardiac surgeon
 General surgeon
 Oncologist
 Speech pathologist
 Psychologist  Non governmental
 Play and drama organization
therapist  Community
 Music therapist  Family members
 Social worker
 Vocational counsellor
 Nature of disease

 Severity of disease

 Freedom to live and work

 Economical stability

 Access to education

 Sexual dysfunction
Bobath Neurodevelopmental
Treatment Approach
 Flacidity- occurs from the time of injury to
2 to 3 days after(decreased or no tendon
reflexes or resistance to passive movement)

 Spasticity-onset 2days to 5 wk(Hyperactive

tendon reflexes and exaggerated response
to minimal stimuli
 Synergy – onset 2–3 wk (Simultaneous
flexion of muscle groups in response to
flexion of a single muscle (e.g., an attempt to
flex the elbow results in contraction of the
fingers, elbow, and shoulder)

 Near normal, slight incoordination may

be present
 Used for patients with hemiplegia caused by
stroke, brain injury, and cerebral palsy.

 Major goal is normalization of muscle tone,

posture, movement, and function
 Reintegration of function of the two sides of the
body.
 Proximal to distal positioning is recommended .
 Weight bearing is provided on the affected side to
normalize tone.
 Tasks should begin from a symmetric midline
position with equal weight bearing on the affected
and unaffected sides.
 Movement toward the affected side is encouraged.
 Straightening of the trunk and neck is
encouraged to promote symmetry and
normalization of tone and posture.
 Hemiplegic patients should be positioned
in opposition to the spastic patterns of
flexion and adduction in the upper
extremity and extension in the lower
extremity
 Importance of Positioning
 prevent development of musculoskeletal
deformities
 Contracture
 Ankylosis(stiffness and rigidty of joints)
 Pressure ulcers
 decreased vascular supply
 Thrombosis
 Edema
 The unconscious patient should be
repositioned every few (e.g., 2 hours) hours

 If spasticity is present, frequent

repositioning is necessary. Splinting and
casting to inhibit tone may be ordered and
applied by a physical therapist.
 Any restrictions of position are posted in
patient file(paper or electronic site).

 A sufficient number of pillows are available

to maintain body alignment.

 Trochanter rolls and other positioning

devices are useful
 If an arm is weak or paralyzed, it is
positioned to approximate the joint space in
the glenoid cavity.

 The affected arm is not pulled. A pillow or

small wedge in the axillary region helps
prevent adduction of the shoulder.
 Special resting hand splints may be
ordered to prevent contracture; remove
periodically to assess the skin for pressure
ulcers

 Reduce edema by elevating the hand higher

than the elbow or by using elastic glove .
 Foot drop- high-top sneakers or special
splints, may be ordered.

 Heels are kept off the bed to prevent

pressure ulcers from developing.

 Pillow placed crosswise to elevate the

lower legs or heel guards may be applied
Wrist support Foot drop boot
splint

Trochanter
Side-Lying Position
 Favourable for unconscious patient
 head of the bed elevated 10 to 30 degrees.
 head should be placed in a neutral position.
 soft collar or towel roll is useful to maintain the
neutral position
 head turned slightly to facilitate drainage of oral
secretions and to maintain a patent airway.
 The conscious patient may sit on the side of the bed,
using the over bed table and pillows for support.

 For the weak, debilitated patient who cannot hold

up the head or neck, a high-back chair that extends
to the top of the head is most effective
 Some patients have a neck brace; apply it for
sitting.
 Pillows or rolls support the arms in the desired
position.
 The feet are positioned flat on the floor. The
pressure on the bottom of the feet assists in
stretching the heel cord.
Neck brace High back chair
Transfer
Types
 Two-person lift: physical transfer by at least two
staff members; no active patient participation

 Mechanical lift: transfer using a lifting device that is

operated by staff members; no active patient
participation
2 person lift
Mechanical lifts
 Contact guard: provision of verbal cues and
minimal physical support during the
activity, such as holding the arm or waist
during ambulation.

 Supervision: provision of verbal cues only,

as necessary
 Transfer toward the unaffected side.

 Patients should wear properly fitted, flat shoes.

 Never tug on the paretic arm by pulling on the upper

arm or shoulder.

 If balance is unsteady, stand on the affected side,

ready to grasp the belt around the patient’s waist.

 If the patient’s knees buckle and additional
assistance is required, stand in front of the
patient and push with your knee against the
patient’s unaffected knee to lock the knee in
position and prevent buckling.

 A walker or four-point cane may be used for

support.
Transfer Activity: From Lying in Bed to a Sitting
Position Hemiplegic Patients.
 Move toward or roll onto the side of the bed on which
you intend to sit.
 Slip the unaffected leg under the affected leg at an angle
so that the unaffected leg becomes a transfer cradle for
the affected limb.
 Place the affected arm on the abdomen or lap.
 Push off the mattress with the unaffected elbow, raising your
upper body, while turning your hips toward the side of the bed
on which you intend to sit.

 Swing the unaffected leg over the side of the bed, and use the
unaffected hand to push up.

 Once in the sitting position, lean on the unaffected hand to

maintain an erect position.
 Paraplegic or Incomplete Quadriplegic Patients.
 Most transfer activities for quadriplegic and some
incomplete quadriplegic patients require direct
assistance from facility personnel.
 Transfer Activity: From a Sitting Position on the
Bed to a Chair
 Place the chair at a slight angle as close as possible to
the bed on the unaffected side.
 With feet close together, lean forward slightly, put the
unaffected hand on the mattress edge, and push off to a
standing position, bearing weight on the unaffected
side.
 Once balance has been maintained and is steady
enough for momentary release of support, move
the strong hand to the farthest arm rest of the
chair.
 Keep the body weight well forward; pivot on the
unaffected foot, and slowly lower to a sitting
position
PHYSICAL THERAPY
Types
 Passive exercises
 Active exercises
 Active assistive exercises
 Resisted exercise
 Manual resisted exercises
 Mechanical resisted exercises
 Isometric or muscle strengthening
exercises
 Patient is rested, comfortable, and pain free to gain
cooperation.
 Position in proper body alignment, and drape, as
necessary, to avoid undue exposure.
 Maintain good posture to ensure efficient body
movement
 Face the patient to observe facial reaction to the
exercises.
• Movements are slow, smooth, and rhythmical.
• Move the body part to the point of Pain ,resistance
and stop.
• If the patient becomes excessively fatigued,
discontinue the exercises.
 Passive exercises
 Smooth rhythmical and accurate anatomical
movements performed by the therapist
within the pain limited range.
 Active exercise
 Exercises which are performed by the
patient himself without any assistance and
resistance by the external force except the
gravity.
 Active assited exercise
 Range of motion to a body joint is
accomplished by the patient with the
assistance of another person
 Resisted exercise
 The activities, which are performed by
opposing the mechanical or manual
resistance is called resisted exercise.
 Types
 Manual resisted exercises
 Mechanical resisted exercises
 Manual resisted exercises
 Resistance can be applied by the patient
himself or by any other person.

 Mechanical resisted exercises

 Mechanical devices are used to oppose the
active movement of a person e.g weights,
pulleys
 Isometric or muscle strengthening
exercises:
 exercises are accomplished by alternately
tightening and relaxing the muscle without
joint movement
 Muscle strengthening exercises
 Strengthen muscles enough to perform a
given function
 As muscle strength increases, resistance is
gradually increased
 Tilt table(for orthostatic hypotension)
 Mat exercise
 Mirror feedback therapy with parallel bars
 Co ordination exercise
 Frenkel’s exercise
 Task oriented exercise
Involves repeating meaningful movement that
works more than on joint and muscles.
 Heat therapy
 Mechanism of action
 Increases bloodflow and the extensiblity of
connective tissue
 Decreases joint stiffness, pain, and muscle
spasm
 Reduces inflammation, oedema and
exudates resolve
 Indication
 Sprains
 Myositis
 Arthralgia
 Neuralgia
 Muscle spasm
 Strains
 Hot pack (containers filled with silicate gel)

 Infra red ray(Applied with lamp )

 Paraffin baath(Wax heated at 49 degree
centigrade)
 Hydrotherapy( warm water 96 to 100)
 Diathermy(use of high-frequency
electromagnetic current )
 Cold therapy
 Electrical stimulation
 Denervated skeletal muscle and innervated
muscle that cannot be contracted
voluntarily can be stimulated electrically to
help alleviate or prevent disuse atrophy and
muscle spasticity.
 Transcutaneous electrical nerve
stimulation(TENS)
 use of electric current to stimulate the nerves

 Uses
 Chronic low back pain

 Neuralgia

 Contusion
 Traction
 Used for extrinsic muscle spasm and to
keep bony surfaces aligned while fracture
heal.
 E.g cervical traction, lumbar traction
 Massage
 Acupuncture
 Biofeedback
 Electromyogram

 Galvanic skin response

 Perception is a complex intellectual
process of recognizing, interpreting, and
integrating sensory stimuli into meaningful
information from the internal and external
environments.
 The parietal lobe is particularly important
in perception.
 Perception of illness
 Body image
 Spatial relationship
 Agnosia
 Apraxia
 Results from injury to the cortex of the left
hemisphere in the posterior frontal or
anterior temporal lobes

 Aphasia -is the loss of ability to use

language and to communicate thoughts
verbally or in writing.
 Stimulate conversation and ask open-ended
questions.
 Allow patients time to search for the words to
express themselves.
 Disregard choice of incorrect words.
 Assure patients that their speech will gradually
improve with time.
 Provide a loose-leaf notebook with pictures of
common objects so that the patient can point
to the picture when unable to say the word.
 Tell the patient that speech skills can be
relearned, given time.
 Anticipate the patient’s needs
 Auditory training

 Lip reading

 Sign board
 Muscle exercise
 E.gMasako Maneuver (Place the tip of your
tongue between your front teeth or gums
and swallow)
 Swallowing is a complex process of
ingesting solid or liquid food while
protecting the airway.
 four phases of swallowing:
 Oral preparatory phase: food is taken into
the mouth and chewed, forming a bolus.
 Oral phase: the bolus of food is centered and
moved to the posterior oropharynx.
 Pharyngeal phase: the swallowing reflex
carries the bolus through the pharynx.
 Esophageal phase: peristalsis carries the bolus
to the stomach.
 Feed or eat in the upright, sitting position at a 90-
degree angle.
 Tilt the head forward and tuck the chin in to prevent
food from moving into the posterior oropharynx
before it has been chewed
 Encourage taking small bites and thorough chewing.
 For patients with hemiplegia or hemiparesis, place
food on the unaffected side.
 If “pocketing” of food is a problem, have the
patient sweep the mouth with his or her
finger after each bite to clear the food.
 The speech therapist can be helpful by
suggesting an adaptive cup and special
techniques to ensure swallowing.
 If oral feeding is contraindicated, a feeding tube
or gastrostomy tube can be considered
 If cognitive deficits are present, the patient
may have poor impulse control and may stuff
the mouth hurriedly with food (manage the
behavior and controlling distractions from the
focus of eating. This patient requires mealtime
supervision and verbal and nonverbal cues)
 Bladder control is an integrated function of
the brainstem, spinal, and cerebral level.
 Alterations in urinary elimination patterns
can be classified generally into urinary
incontinence (UI) and urinary retention
 Urinary incontinence can be associated
with various problems, such as a
diminished level of consciousness; cerebral
injury, especially to the frontal lobe; or
spinal cord injury.
 Four major categories
 Urge incontinence: the involuntary loss of urine
associated with an abrupt and strong desire to void
(urgency).
 Stress incontinence : the involuntary loss of urine
during coughing, sneezing, laughing, or other
physical activities that increase abdominal pressure.
 Overflow incontinence : the involuntary
loss of urine associated with overdistension
of the bladder.
 Functional incontinence : urine loss
caused by factors outside the lower urinary
tract; this category includes UI
 Urinary retention is often associated with
spinal cord–injured patients.
 Bladder Training. Bladder training, also called
bladder retraining, includes several variations.
 Three primary components of education,
scheduled voiding, and positive reinforcement.
 The patient needs to be educated to understand
the physiology,pathophysiology, technique, and
desired outcome.
 A bladder retraining program assists the
patient to learn to resist or inhibit the
sensation of urgency, postpone voiding, and
urinate according to a timetable rather than
the urge to void.
 The initial goal interval may be 2 to 3 hours,
although it is not followed during sleep
 Prompted Voiding.
 Prompted voiding is a technique used primarily with dependent
or cognitively impaired people.
 Monitoring: the person is checked by caregivers on a regular
basis.
 Prompting: the person is asked (prompted) to try to use the
bathroom to void.
 Praising:the person is praised for maintaining continence and
attempting to use the toilet
Pelvic Muscle Exercises.
 also called Kegel exercises, comprise a
behavioral technique that requires repetitive
active exercise of the pubococcygeus muscle to
improve urethral resistance and urinary
control by strengthening the periurethral and
pelvic muscles in women.
 contracted to a count of 10 and then relaxed
to a count of 10.
 About 50 to 100 of these exercises must be
done daily to be effective. It takes about 4 to
6 weeks to notice improvement.
 Bladder-Triggering Techniques
 A few bladder-triggering techniques facilitate
bladder emptying.
 They include suprapubic stimulation,
Valsalva’s maneuver, and Credé’s maneuver.
Suprapubic stimulation
 suprapubic stimulation
 activates the sacral-lumbar dermatomes by manually tapping
the suprapubic area, pulling pubic hairs, or stroking the
medial thighs.

 Valsalva’s maneuveris
 straining against a closed epiglottis while contracting the
abdominal muscles and bearing down on the bladder. The
straining is sustained or the breath held until the urine flow
ceases..
 Credé’s maneuver
 placing the hands flat just below the
umbilical area and pressing firmly down and
inward toward the pelvic arch. The purpose
of this maneuver is to express urine from the
bladder
 Catheters and Catheterizations
 Intermitten catheterization

 Suprapubic catheterization

 indwelling catheterization
 The act of bowel evacuation is called
defecation.
 The anus, the terminal end of the large bowel,
is controlled by two sphincters: the
involuntary proximal anal sphincter (smooth
muscle) and the voluntary distal anal sphincter
(striated muscle).
 Defecation is a coordinated reflex involving
sacral segments S-3, S-4, and S-5, which is
initiated by stimulated stretch receptors
located in the anus that initiate peristaltic
waves.
 Types of Altered Bowel Function Patterns
 Constipation
 Diarrhea
 Incontinence
 Constipation: fluid restriction, prolonged
immobility, nothing by mouth status as a result
of swallowing deficits or unconsciousness,
decreased bulk in diet, drugs known to
decrease peristalsis (e.g., codeine), spinal
nerve compression, paralytic ileus, lack of
sensation, lack of privacy, interruption of usual
bowel routine, and failure to respond to
defecation stimuli
 Diarrhea: intolerance to tube feeding,
antibiotic therapy, and fecal impaction .
 Incontinence: altered consciousness, cognitive
deficits (e.g., social disinhibition, lack of impulse
control, inability to recognize and respond to
defecation impulses), impaired communication, and
neurogenic bowel without sensation or control
(related to spinal cord injury above T-11 or
involving sacral reflex arc S-2 to S-4)
 Make sure the lower bowel is empty; an enema may
be necessary before beginning the training program.
 Establish a time of day for a bowel movement based
on the patient’s previous pattern; adhere to this
designated time of day rigidly.
 Encourage a diet high in roughage (whole-grain
bread and cereal, fresh fruits, and vegetables).
 Unless contraindicated by a fluid
restriction, increase fluid intake to 2000 to
2500 mL/d.
 Insert a suppository on the first day. If it
does not work, you may wait until the next
day.
 The patient should be seated on the commode or
taken into the bathroom to defecate.

 Administer medications and collaborate with patient

and health team members to adjust regimen
individualized to the patient
 Neurological disorders and its
rehabilitation
 Stroke is when poor blood flow to the brain
results in cell death.
 There are two main types of stroke:
ischemic, due to lack of blood flow, and
hemorrhagic, due to bleeding.
 They result in part of the brain not
functioning properly
 Positioning
 Mobilization and stretching
 Weight bearing activities
 Chest physiotherapy
 Pain relief
 Speech therapy
 Bowel and bladder care
 Title -A randomized controlled trial on the immediate and long-term
effects of arm slings on shoulder subluxation in stroke patients

 Author : VAN Bladel A, Lambrecht G, Oostra KM, Vanderstraeten

 Year of publication:2017,jan

 Objectives To determine both the immediate and long-term effect on

acromiohumeral distance using the Actimove® sling and Shoulderlift

(V!GO, Belgium) and to determine the effect of slings on pain and

passive range of motion of the shoulder in stroke patients with

glenohumeral subluxation
METHODS:

 28 stroke patients, with severe upper limb impairments, were

randomly allocated to 3 groups (Actimove, Shoulderlift, No sling).

Patients wore their supportive device for 6 weeks and no sling in

the control group. Immediate and post-interventional effect on

acromiohumeral distance was measured using sonography. Pain

(VAS), ROM (goniometry), spasticity (Modified Ashworth Scale),

Fugl-Meyer Assessment and trunk stability (TIS) were also

assessed before and after the intervention.

 RESULTS:
 The level of immediate correction of both slings was different at baseline and
after 6 weeks (0 weeks: Shoulderlift 63%, Actimove 36%; 6 weeks: Shoulderlift
28%, Actimove 24%). Comparing the level of subluxation over time shows a
distinct decrease in subluxation but only for the control group (-37.59% or
3.30 mm). Subluxation remained the same in the Actimove group (- 2.77 % or
0.27mm) but increased in the Shoulderlift group (+ 12.44% or 1.03 mm).
 After 6 weeks, the Actimove group reported more pain at rest (p = 0.036). ROM
for abduction and external rotation decreased in 2 groups and remained un-
altered in the Shoulderlift group
 CONCLUSIONS:
 Results of immediate correction varied.
Subluxation seemed to reduce in patients
that did not wear a sling.
 A brain injury is any injury occurring in
the brain of a living organism. Brain injuries
can be classified along several dimensions
 Positioning, transfer
 Supportive eating and standing
 Rehabilitation of motor control
 Bowel and bladder care
 Pain
 Training balance
 Aids to improve memory
 A spinal cord injury (SCI) is damage to the
spinal cord that causes changes in its function,
either temporary or permanent.
 These changes translate into loss of muscle
function, sensation, or autonomic function in
parts of the body served by the spinal cord
below the level of the lesion
 Safe transportation
 Traction
 Positioning
 Active and passive ROM
 Mat work
 Orthoses (spinal corsets, crutches)
 Gait trainning
 Mobility training
Title -Spinal cord injury rehabilitation in Riyadh, Saudi
Arabia: time to rehabilitation admission, length of stay and
functional independence.
Authors: Mahmoud H, Qannam H, Zbogar D
Year of publication:2017,jan
Objectives -To describe functional status, length of stay
(LOS) and time to rehabilitation admission trends.
To identify independent predictors of motor function
following rehabilitation
 METHODS:
 From chart review of 312 traumatic and 106
nontraumatic adult patients with spinal cord injury
(SCI) we extracted information on time from injury to
rehabilitation admission, rehabilitation LOS, Functional
Independence Measure (FIM) motor score (admission
and discharge), American Spinal Injury Association
Impairment Scale (AIS) grade and demographics..
 RESULTS:
 Mean±s.d., median days from injury to
rehabilitation admission were 377±855, 150 days
for traumatic SCI and 288±403, 176 days for
nontraumatic SCI. For individuals with traumatic
SCI, after accounting for admission FIM motor
score, tetraplegia and time from injury to
rehabilitation admission had a significant but
small negative association with discharge FIM
motor score.
 Parkinsonism is a clinical syndrome
characterized by tremor, bradykinesia,
rigidity, and postural instability.
 Reduction of rigidity and maintaining
flexibility
 Balance training
 Coordination exercises
 Breathing and chest expansion exercises
 Improvement in psychological well being
 Guillain–Barré syndrome (GBS) is a rapid-
onset muscle weakness caused by the
immune system damaging the peripheral
nervous system
 Chest physiotherapy
 Maintenance of range of motion of all joints
 Psychological support
 Prevention of postural hypotension
 Strengthening
 Gait training
 Coordinates various aspects of patient care in
hands on manner, identifying day to day problems
and monitoring progress.
 Liaises between various team members of the
rehabilitation team and looks after critical
executive function like positioning, splinting,
hygiene
 Acts as spokes person for the patient to highlight
their problems and needs to the team.

 Provide psychological support.

 Create awareness of the problem in the

community.
SUMMARY
 Rehabilitation is a combination of methods
that are focused in restoring the patient’s
useful life.
 Rehabilitation could help one body achieve
the normal daily functions by different kinds
of recovery techniques.
Books

 Clement. Textbook on neurological and neurosurgical nursing.1sted. Newdelhi.Japee

brothers medical publishers.p553-58

 Sundar S. Textbook of rehabilitation.3rd ed. Newdelhi . Jaypee brothers medical

publisher.p.13-40

 Narayanan S lakshmi. Textbook of therapeutic exercises.6th ed. New delhi. . Jaypee

brothers medical publisher.p.13-40.

 Hickey J. the clinical practice of neurological and neurosurgical nursing. 7thed.

Wolters and kluwer.p. 224-56

 Smeltzer Suzanne C, Barebrenda G, Hinkle Janice L, Cheever Kerry H. Textbook of

medical surgical nursing, 12th ed. Newdelhi: Lippincot wolter’s kluwer; p.113-
 Journals
 Mahmoud H, Qannam H, Zbogar D.Spinal cord injury rehabilitation in Riyadh,
Saudi Arabia: time to rehabilitation admission, length of stay and functional
independence. Spinal cord.2015 jan. 4(1)
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 Internet
 https://en.wikipedia.org/wiki/Pain_management
 https://en.wikipedia.org/wiki/Rehabilitation
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