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Cardiovascular medicine
usual care group did not significantly improve, but with no significant differences
between the groups. At 12months follow-up, there was a decline in 6MWT in both
groups; 55.2m (95 CI: 18.7 to 91.7, p<0.01) in the home group and 52.1m (95
CI: 3.0 to 107.1, p=0.06) in the usual care group. There were no significant
differences in blood pressure, body composition, cholesterol profile, cessation of
smoking or HRQoL after 3, 6 and 12months follow-up.
Conclusions Participation in home-based CR improved exercise capacity
among elderly patients with coronary heart disease, but there was no significant
difference between the home intervention and the control group. In addition, no
significant difference was found in the secondary outcomes. When intervention
ceased, the initial increase in exercise capacity was rapidly lost.
Article summary
Article focus
disability.
When the home-based intervention ceased, the effect was rapidly lost.
patients.
The duration of the intervention may be too short to maintain changes in
exercise capacity at 12months of follow-up.
Introduction
Participation in cardiac rehabilitation (CR) is often the first step towards
optimal secondary treatment and prevention, and is recommended to patients with
coronary heart disease. The centre-based programmes are the cornerstone in the
evidence of CR, with meta-analysis showing an approximately 20 reduction in allcause and cardiac mortality and 17 reduction in re-infarction rate among patients
who participated in the programmes.1 ,2 CR is also found to be effective among the
elderly age 65years.3 ,4 However, one of the main problems in centre-based CR is
the low participation rate among patients in general and among elderly patients in
particular. Participation rates are reported to be as low as 30 of eligible
patients5 but, among elderly patients, participation rate is even lower.4 In addition,
adherence rate to the centre-based programmes are low and drop-out rates are
high.6
In order to improve access and participation rate, there has been an increasing
focus on home-based CR where the entire programme, or parts hereof, is moved
from the centre to the patient's home. This could be an attractive alternative to
centre-based CR. Several guidelines have advocated for home-based CR79 and
these programmes are now the main alternative to the centre-based programmes.
We have recently published a randomised clinical trial (RCT) comparing
home-based CR with centre-based CR in elderly patients with coronary heart
disease.10 The study showed that home-based CR was not inferior to centre-based
CR, which is in accordance with a Cochrane review from 2010.11 A review from
2006,12 comparing home-based programmes with usual care (no rehabilitation)
found a significantly better outcome in systolic blood pressure and in the likelihood
of being a smoker. The home-based programmes had also better outcomes with
regard to exercise capacity, total cholesterol, anxiety and depression score, although
these data did not reach statistical significance. A limitation in the reviews and
meta-analyses1113 is that the included populations are highly selected with few
elderly patients and excluding patients with comorbidity and disability. Since
elderly patients with coronary heart disease is the fastest-growing subgroup of
cardiac patients there is an increasing need for adjusting the CR programmes
according to their requirements.
The aim of this study is, in a randomised design, to compare the effect of
home-based CR with usual care (no rehabilitation) in a population of patients 65
years with coronary heart disease, who declined participation in a centre-based CR
programme.
Methods
Trial design
The study is a randomised clinical trial comparing home-based CR with usual
care. Inclusion criteria were patients 65years with a recent coronary event defined
as acute myocardial infarction (MI), percutaneous transluminal coronary
intervention (PCI) or coronary artery bypass graft (CABG) and who declined
participation in centre-based CR. Exclusion criteria were mental disorders
(dementia), social disorders (severe alcoholism and drug abuse), living in a nursing
home, language barriers or use of wheelchair. Figure 1 shows the flowchart.
In a new window
Figure 1
Flowchart.
Patients were recruited from our Rehabilitation Unit which offers centre-based
CR to all patients with coronary heart disease assigned to the hospital. In order to
ensure that all patients receive the CR treatment offer, the referral procedure is
centralised and computerised with identification of patients from a database
covering diagnosis and all invasive procedures performed in the catchments area of
Bispebjerg University Hospital, Copenhagen. Patients are consecutively invited by
letter and non-responders are additionally contacted by telephone. At the first visit
in the Rehabilitation Unit, patients were invited to participate in the previously
mentioned RCT comparing home-based CR with centre-based CR,10 or as an
Usual care
This group is equivalent to a non-rehabilitation control group. Patients were
not offered exercise education or dietary counselling but, as for the home group,
offered risk factor intervention and medical adjustment by a cardiologist at baseline
and after 3, 6 and 12months. Telephone calls were made at 4 and 5months. Thus,
this group received solely consultation at a cardiologist which is offered to all
patients in daily clinical practise who decline participation in our comprehensive
centre-based CR programme.
Outcome measures
Because many patients, owing to age and comorbidity, were not able to
perform a symptom-limited exercise capacity test, the primary outcome was change
in exercise capacity determined by 6min walk test (6MWT). The secondary
outcomes were: sit to stand test (STS), self-reported level of physical activity,
systolic and diastolic blood pressure, total-cholesterol, HDL-cholesterol and LDLcholesterol, body mass index, waisthip ratio, proportion of smokers, health-related
quality of life (HRQoL) measured by SF-12, and anxiety and depression estimated
by Hospital Anxiety and Depression Scale (HADS). Outcomes were evaluated after
3, 6 and 12months.
In the STS-test, the patients must, as fast as possible within 30s, change
position from sitting on a chair to upright standing, without holding the handgrip,
hereby measuring the strength in the lower limb. Self-reported level of physical
activity was estimated by a questionnaire originally developed by Saltin and
Grimby.16 It has four categories ranging from a sedentary lifestyle, to performing
light activities 24h/week, activity more than 4h/week or highly vigorous physical
activity more than 4h/week. Patients in the last three categories were classified as
having an active lifestyle. Medication included the use of diuretics, -blockers,
calcium antagonists, lipid-lowering drugs, antithrombotics, antidiabetic and
antidepressive treatment. Sociodemographic data included level of education, main
employment status, contact to children, living alone and the need of weekly
assistance at home. Patients in NYHA IIIV and CCS IIIV were categorised as
having dyspnoea and angina, respectively. Comorbidity was assessed by The
Charlson Co-Morbidity Index (CMI),17 which measures the burden of 19 comorbid
conditions through a weighted index. The CMI was categorised in 3 subgroups: 0
(no comorbid condition), 12 and 3 (high level of comorbid burden).
Adverse events were recorded in the study period and included admissions for
MI, progressive angina, decompensated congestive heart failure, severe bleeding,
new malignant disease and performance of PCI. Moreover, the number and duration
of hospital admissions were recorded 1year after randomisation. Death data were
obtained from the Civil Registration System, which records the vital status of all
citizens in Denmark.
Statistical analysis
To test the effect of the interventions at 3 and 12months, a mixed model of
regression analysis was used with a timetreatment interaction term. We used a
mixed model in order to analyse the effect of the interventions, since this statistical
model allow us to include all data into one analysis. All the models were adjusted
for age and gender. We did not adjust the significance levels for multiple testing,
since such an adjustment is a too conservative test to perform, when data are
positively correlated, as in this study.
Data were analysed by intention to treat. All statistical analysis was performed
using STATA for windows release V.10.0.
Results
A total of 40 patients participated. Baseline characteristics are listed in table 1.
All patients received antithrombotics and lipid-lowering drugs and 77.4 received blockers.
View this table:
In this window
In a new window
Table 1
Baseline characteristics according to intervention
Of eligible patients to receive CR (n=284), a total of 49 (n=140) declined to
participate in the centre-based programme (figure 1). Of these, 29 accepted to
participate in this study and 71 (n=100) did not receive any rehabilitation.
Exclusion rate was 10 mainly because of language barriers (n=13), social
disorders (n=5), dementia (n=5) and other reasons (n=7).
Exercise capacity
Figure 2 illustrates the unadjusted means of the primary outcome
measurement of 6MWT from baseline to 12months follow-up. The figure shows a
significant increase in walking distance of 33.5m (95 CI 6.2 to 60.8, p=0.02) in the
home group after the intervention followed by a significant decline of 55.2m (95
CI 18.7 to 91.7, p<0.01) at 12months follow-up to a level lower than the baseline
value. Patients in the usual care group had a non-significant increase in walking
distance of 10.1m (95 CI: 19.3 to 39.5, P=0.5) after 3months followed by a
decline of 52.1m (95 CI 3.0 to 107.1, p=0.06) at the end of the follow-up
period. When adjusting for age and gender in a mixed model with a timetreatment
interaction term, there were no significant differences between the groups at 3
months (table 2). At 12months follow-up, a significant decline in 6MWT and STS
was found in both groups with no differences between the groups (table 3).
View this table:
In this window
In a new window
Table 2
Effect of intervention at 3months follow-up
View this table:
Table 3
Follow-up data at 12months
In this window
In a new window
In a new window
Figure 2
Changes in mean values of 6-min walk test. *p Value between 3 and 12
months.
Other outcomes
A higher proportion of patients reported a change from an inactive to an active
lifestyle in the home group (27, p<0.05) compared to the usual care group (5,
p=0.6), after the intervention with a difference between the two groups of 33
(p<0.05). At 12months follow-up, the proportion of patients with a self-reported
active lifestyle declined again in the home group with no changes in the usual care
group.
There were no significant differences in clinical status, exercise capacity,
laboratory values, HRQoL or anxiety and depression score at 3 and 12months
follow-up either within or between the groups.
The number and length of acute and non-acute admissions were equally
distributed at 12months follow-up (data not shown).
A total of nine patients died during a mean follow-up of 4.5years (usual care
group n=5 and home group n=4). There was no loss to follow-up.
Discussion
To the best of our knowledge, this is the first study to investigate the effect of
home-based CR compared to usual care (no rehabilitation) among elderly patients
65years with coronary heart disease who declined participation in a centre-based
programme. In many countries, including Denmark, centre-based programmes are
often the only cardiac rehabilitation programme available, and the limited access to
CR may be an important barrier for optimal secondary treatment and prevention in
elderly patients with coronary heart disease.
The study found that elderly patients who decline participation in centre-based
CR had a low level of exercise capacity and a high level of comorbidity. For this
population, who is often found not to be eligible to centre-based CR, home-based
CR was feasible. There was a trend towards clinical relevant improvement in
6MWT, but these changes were not statistically significant compared to the control
group. Although the study is small and conclusions must be drawn with caution, it
could identify an intervention targeting this group of patients. After having ended
the home programme, the gained improvement in exercise capacity was not
sustained.
Exercise capacity
The effect of our home CR programme on exercise capacity is consistent with
the findings in the only other study investigating the effect of home-based CR and
usual care among elderly with coronary heart disease.3 In this study, patients in the
age groups 4565years, 6675years and >75years significantly improved their
exercise capacity after participating in a home programme, although the
improvement was less among the very old patients (>75years).
The meta-analysis by Jolly et al,12 which included studies of all age groups,
investigated the effect of home-based CR and usual care. The meta-analysis showed
an improvement in exercise capacity but could not identify any significant
differences between the home and usual care group. The authors explained this by
the possibility that patients in usual care groups may receive input that match the
homeinterventions and thus diminish a possible difference. This could also have
been the case in our study.
At 12months, a significant decline in exercise capacity was found in both the
home and usual care group reaching a level lower than at entrance to the study. We
identified two other studies with long-term follow-up.3 ,18 In contrast to our study,
patients, who initially declined centre-based CR, did accept to participate in this
study and the proportion could have been even higher if the home-based CR
programme was not part of an RCT study. Thus, with alternative concomitant CR
programmes, accessibility increases and participation rate will be expected to rise.
The main limitation of this study is the number of patients included. With the
additionally large variation in the effect of intervention as reflected in the wide CIs,
there is a risk of type II error. However, wide variations in the effect of intervention
are often seen in exercise trials and our results are in concordance with other much
larger exercise trials.22 ,35 The strength of our study is the randomised design and
the unselected population of elderly patients with high comorbidity, which probably
makes our population more representative of the elderly population in daily clinical
practice.
Conclusion
In this study of patients 65years with coronary heart disease, home-based
CR improved exercise capacity, but there was no significant difference between the
home intervention and the control group. In addition, no significant difference was
found in the secondary outcomes. The study found that elderly cardiac patients who
declined participation in centre-based CR had high level of comorbidity and low
exercise capacity. These characteristics indicate that results from exercise trials
excluding this group of patients should be cautiously applied to the elderly
population. After cessation of the home intervention, the gained improvement in
exercise capacity was rapidly lost. This emphasises that close follow-up with
continuous guidance beyond the initial rehabilitation period is important. This study
could contribute to the scientific gap on how to manage the large population of
elderly cardiac patients who are not interested in (or capable of) participating in a
centre-based CR programme. Larger trials of unselected older patients are needed in
order to confirm our findings and ways to overcome the barriers for adherence to
exercise training has to be established.
Acknowledgments
The authors would like to thank the physiotherapists, nurses and dieticians
involved in the study.
Footnotes
plan, analysed the data and revised the draft paper. MF designed the study and
collected some of the data and revised the paper. JFH designed the study and
revised the draft paper.
Ethics approval The study was approved by the Local ethics committee
in Copenhagen, Denmark, (jr.nr.KF01327990) and the Danish Data Protection
Agency (j.nr. 2006-41-7212).
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a randomized trial with preference armsCornwall Heart Atta
naintea celuilalt;
paii s fie egali;
contactul cu solul s se ia pe toc;
flexia coapsei pe bazin s se efectueze fr ridicarea oldului.
5.3. Rezultate
n urma studiului efectuat pe cele dou loturi rezultatele, n cazul
Lotului Martor au artat c reluarea mersului s-a realizat dup 3 luni de
la producerea accidentului vascular cerebral, iar n cazul Lotului
Experimental acest obiectiv s-a realizat dup 2 luni de la instalarea
hemiplegiei.
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Prevenire:
- controlul tensiunii arteriale;
- combaterea aterosclerozei si prevenirea accidentelor trombembolice;
- decelarea precoce a compresiunilor cerebrale - investigaia cu tomograful
sau RMN imediat ce apar semne ale bolii (dureri de cap, greuri, ameeli etc.). O
nlturare precoce a formatiunii tumorale poate face tratamentul de recuperare mult
mai simplu i mai eficace.
- prevenirea traumatismelor cerebrale - hemiplegiile provocate de traumatisme
cerebrale pot fi evitate dac vom lua unele msuri de protecie. Astfel, cnd mergem
cu bicicleta, este bine s purtm o casc de protecie, cnd mergem cu maina este
bine s folosim centura de siguran care, n caz de accident rutier, ne ferete de a fi
proiectai prin parbriz. Cnd mergem la vntoare este bine s nu stm pe direcia
de tragere a partenerilor de plceri cinegetice.
Odat hemiplegia instalata, pacientul va intra n sfera de activitate a echipei de
recuperare, care este format din medici de diverse specialiti, kinetoterapeui,
ergoterapeui, logopezi, asistente medicale i infirmiere.
Evaluare functionala:
Aprecierea functiilor vitale: respiratie, deglutitia, masticatia, controlul
defecatiei si al vezicii urinare.
Aprecierea activitatii mintale si a capacitatii de comunicare (verbala, scrisa,
prin mimica)
Aprecierea sensibilitatii exteroceptive si proprioceptive a perceperii corpului.
Aprecirea abilitatii motorii (reflexe si reactii reflexe, tonus muscular,
coordonare pe partea neafectata, abilitatea miscarii trunchiului si a partii afectate).
Aprecierea controlului motorin diverse situatii posturale(mobilitate, stabilitate,
mobilitate controlata, abilitate)
Aprecierea activitatilor zilnice (ADL=Activities of Daily Living)
Aprecierea amplitudinii miscarilor articulare
Aprecierea integrarii familiale, sociale, ocupationale a pacientului.
Pe baza evaluarii functionale pacientii pot fi incadrati in trei stadii:
initial,mediu(de specialitate) si avansat (de refacere) considerandu-le in scurgerea
timpului de la momentul accidentului cerebral spre momentul refacerii, ma mult sau
mai putin complet
Obiective generale:
- refacerea fortei musculare si cresterea rezistentei musculare;
- cresterea si adaptarea capacitatii de efort;
- ameliorarea functiei de coordonare, control si echilibru a corpului;
- formarea capacitatii de relaxare;
- corectarea posturii si aliniamentului corpului;
- cresterea mobilitatii articulare;
- reeducarea respiratorie;
- reeducarea sensibilitatii.
Mijloace:
- Mobilizari active, pasive, autopasive
- Electroterapie
- Masaj
Tratamentul:
Se cunosc trei nivele ale reabilitarii, atingerea carora au loc prin diferite
mecanisme:
I nivel. Restabilirea - este vorba de restabilirea functionala a zonelor de
inhibitie de protectie.
Inhibitia de protectie este o masura fiziologica uneori capata caracter
patologic, durind timp indelungat si facind imposibile restabilirea functiilor.
Deaceea uneori o hemiplegie poate dura mult timp, leziunea neuronala fiind
minimala. Masurile medicale trebuie intreprinse anume la acest nivel, pentru a
dezinhiba elementele nervoase si stimularea lor si aceasta se poate obtine prin
aplicarea gimnasticii curative, masajului, fizioprocedurilor.
Acest nivel se obtine in primele 6 luni dupa accidentul vasculr cerebral.
II nivel. Compensatia - functia structurii lezate este preluata de alta structura
indemna.
Mecanismul ce permite sa atingem nivelul compensatiei il prezinta
reorganizarea compensatorie - dar la acest nivel nu se atinge o restabilire completa a
functiilor, miscarile sint schimbate, cu defect.
III nivel. Readapterea, adaptarea catre defect
In prezenta unui defect evident, cu leziune neuronala masiva lipseste
posibilitatea compensarii din cauza afectarii difuze a cortexului. La pacient gradul
handicapului va fi evident si persistent.
In momentul in care se poate pozitiona in sezut se va aseza cu picioarele
coborite. In timpul asezarii piciorului sanatos periodic se aranjeaza pe cel bolnav
pentru a repartiza masa corpului pe partea afectata.
>>>>>>>>>
Tratamentul kinetic.
Recuperarea va ncepe cu o posturare a pacientului n pat pentru evitarea
apariiei poziiilor vicioase, a durerilor i a escarelor.
Se vor face apoi mobilizri pasive, exerciii de reluare a poziiei eznd i a
ortostatismului i mersului.
De asemenea o atenie deosebit trebuie acordat membrului superior.
n timpul recuperrii pot fi folosite diferite materiale de asisten: fotoliul
rulant, bastoane tri sau tetrapod, crje canadiene sau orteze.
Dac prima parte a tratamentului se va desfura n instituii specializate,
partea a doua i mai lung se va desfura acas. n aceast perioad sprijinul
familiei este de o importan capital. Astfel, familia trebuie s l ajute pe pacient s
se reintegreze n societate i profesional.
Masurile de baza ale recuperarii medicale in hemiplegie sunt:
1. Kinetoterapia
2. Psihoterapia
3. Terapia prin munca
4. Tratamentul medicamentos
5. Fizioterapia
Masurile de recuperare se incep cit mai precoce, dar dupa stabilizarea
bolnavului. Gimnastica pasiva ce include kinetoterapia, masajul si gimnastica
respiratorie incepe din primele zile.
Gimnastica activa este strict individuala si depinde de caracterul accidentului
vascular cerebral.
Kinetoterapia cuprinde:
Posturarile exista diferite scheme de aranjare a membrilor paretice pentru
prevenirea aparitiei contracturilor.
Alternarea periodica a pozitiei membrelor in pozitia bolnavului pe spate si pe
o parte.
Alternarea pozitiilor pe spate, partea sanatoasa si partea bolnava.
I. Decubit dorsal:
Capul pe perna, gitul flectat, umerii se sustin cu perna. Mina paretica se
aranjeaza pe perna la distanta de la corp, indreptata in articulatia cotului si mainii,
degetele intinse. Coapsa paretica este in extensie si pusa pe perna.
II. Decubit lateral pe partea paretica:
Capul se stabilizeaza intr-o pozitie comoda, trunchiul putin intors si se
mentine din spate. Coapsa piciorului paretic se aranjeaza in extensie, articulatia
genunchiului in flexie usoara. Mana paretica sa intinde pe perna. Mana sanatoasa se
aranjeaza pe perna sau pe corp. Piciorul sanatos pozitie pe perna usor flectat in
articulatia genunchiului si coxofemorala.
III. Decubit lateral pe partea sanatoasa:
Capul in prelungirea trunchiului, trunchiul usor flectat anterior. Mina paretica
se aranjeaza pe perna, flectata in articulatia umarului sub un unghi de 90grd si
intinsa. Piciorul paretic usor flectat in articulatia coxofemurala si articulatia
genunchiului, gamba si planta sint asezate pe perna. Mana sanatoasa ocupa o pozitia
comoda. Piciorul sanatos se aranjeaza in extensia articulatiei genunchiului si
articulatia coxofemurala. La tratarea prin pozitie se va tine cont ca mana si
articulatia umarului membrului paretic sa se afle la acelasi nivel pentru a evita
a t e r o c l e r o z a ; -incapacitate functionala;-prezinta o
paralizie flasca.
manevrele folosite: -neteziri circulare energice se executa cu podul palmeiin jurul zonei
interesate2.Posturi:Pozitia pacientului este schimbata din 2 in 2 ore astfel incat zonele
supusecomresiunii pe planul patului sa fie alternante.a).Din decubit dorsal:-se mobilizeaza
pasiv de catre kinetoterapeut toate membrele si segmentele, petoate directiile de miscare.(13)kinetoterapeutul executa exercitii passive de intindere pe toate segmentele siderectiile de
miscare(12)Recuperarea in stadiul post-acut:Masajul(8 membru inferior+8 membru
superior)-exercitii de ridicare in sezut la marginea patului, ridicarea se face cu
ajutorulmembrelor sanatoase(20)-se executa exercitii de respiratie profunda din diferite
pozitii(4)
.2.2.
Muchii braului
Regiunea anterioar
9?icepsul rahial fle xia anteraului pe ra, uoarrotaie
nuntru. ;oracorahialul flexia raului i adducie.?
rahialul flexia anteraului pe ra. Regiunea posterioar 9
Jricepsul ranhial extensiaanteraului pe ra.
E.2.C. Muchii antebraului:
Regiunea anterioar 9Rotundul pronator fle xia ante raului pe
ra.U l e x o r u l r a d i a > a l c a r p u l u i f l e x i a m i n i i p e
a n t e & ra i a anteraului pe ra.U l e x o r u l c u i t a l a l c a r p u l u i
f l e x i a m i n i i p e a n t e & ra n sens cuital i anteraul pe ra.Nungul
palmar fle xia minii pe antera.U l e x o r u l c o m u n s u p e r f i c i a l a l
degetelor flexia fa&langc'or $$ pe $ i secundar degetele
pe palm, palma pea n t e r a i a n t e r a u l p e r a . Ulexorul
comun profund al degetelor flecteaz falanga$ pe $$, mna pe
antera.U l e x o r u l p rop r i u a l p o l i c e l u i f l e c t e a z u l t i m a
f a & l a n g a p o l i c e l u i l a a d d u c i e i a d u c i e p e m n . Ptratul
pronator pronaa. Regiunea extern 9N u n g u l s u p i n a t o r f l e x i a
a n t e r a u l u i p e r a , p r o & n a i e , s u p i n a i e . Nungul extensor
radial al carpului extinde metacar& pul $
$ pe carp i carpul pe antera.0 c u r t u l e x t e n s o r r a d i a l a l c a r p u l u i
l a f e l c a l u n g u l extensor
ului.
3=i. K. ?
4xerciiul # (123+.
/uchiul supinator
supinaie.Regiunea posterioar 9 muchii superficiali4xtensorul comun al
degetelor 4xtensorul propriu al degetului mic4 xtensorul cu ital al
carpului 8nconeul/uchii profunzi 9Nungul adductor al policelui0curtul
extensor al policeluiNungul extensor al policelui4xtensorul propriu al indexului
E.2.K. #uhii miinii
Regiunea palmar extern 90curtul aductor al policelui0curtul flcxor
al policeluiFpozantul policelui8dductorul
policeluiRegiunea palmar intern 9Palmar cutanat8dductorul
degetului mic 0curtul flexor al degetului micFpozantul degetului
micRegiunea palmar mi5locie Nomlicali$merosoi 3
palmari # dorsali
5rinipalelemiri ale membrelor smt:
4xtensia ndeprtarea unui segment de segmen t u l c u c a r e
e s t e a r t i c u l a t ( a n t e r a u l s e n d e p r t e a z d e ra+.
8nteducia
L
ducerea raului nainte. Retroducia ducerea raului napoi. . 3 .
4xerciii pentru recuperarea mem rului superior T i n n d c o n t
d e f a p t u l c s e g m e n t e l e m e m rel o r a c & ioneaz dependent
unul de cellalt formnd ansamlulf u n c i o n a l a l m i n i i i
r e s p e c t i ! a l p i c i o r u l u i n m u n c a de recuperare treuie
acordat atenie tuturor grupelor de m u c h i c e c o n t r i u i e l a
m o i l i z a re a l o r.M e m i p l e g i a 0 Y c a r a c t e r i z e a z p r i n
p i e rde rea m i c & rilor fine selecti!e
i realizarea unor micri grosolane,nefinisate care n
general nu&i ating oiecti!ul. 4le sntg l o a l e c u
predominen la memrul superior fr a ex&clude de
c e l e m a i m u l t e o r i i m e m r u l i n f e r i o r, n
m o & ilizarea memrului superior n cazul hemiplegiilor deo i c e i
m u s c u l a t u r a s c a p u l o h u m e r a l e s t e c e a c a r e i n & ter!ine
n deplasarea acestuia, deoarece aceast muscula& l u r
este a5uttoare pentru muchii principali ai raului.0e
impune deci ca micrile s fie n!ate corect, s nuse
permit sustituia muscular i repetarea s se
f a c pna la instalarea stereotipurilor dinamice. @up cum ama r t a t n
p a g i n i l e a n t e r i o a re l a m e m r u l s u p e r i o r d o m i & nant este
m u s c u l a t u r a f l e x o r i l o r, d e c i t r e u i e i n s i s t a t n m o d d e o s e i t
p e a c t i ! i t a t e a e x t e n s o r i l o r.
E.C.. 4)er iii pasive
4'
=i. D.
4xerciiul 6 (12+.
etelor (fig. 1)+.
=i. <M.
4xerciiul ).
$ndicaii9 8cest e xerciiu se !a repeta la nceput numai d e 2 3
ori deoarece muchii ce snt solicitai snt micii oosesc
f o a r t e r e p e d e . 4xerciiul
6P o z i i a d e p l e c a r e d e g e t u l m a r e p e d o s u l p a l m e i pacientului, c
elelalte # degere n 'palma pacientului(fig. 16+.3"
(fig.18
Exercitiul 7
participe. Dac nu primii nici un rspuns din partea aces&t u i a
ncercai s executai acest exerciiu cu micri
s a & cadate punnd mna pe muchiul triceps i solicitnd
p a & cientului ncordarea acestui mu chi.
p.42
4xerciiul -P o z i i a d e p l e c a r e m n a d r e a p t p r i z a
A a a t , m n a sting cuprinde de sus raul pacientului (fig.1"+. Ulexia
la " grade a anteraului
(fig.19
Exercitiul 8
4xerciiul - (1 23#+.
$ndicaii 9 dup ce pacientul execut acest exerciiu singurncepei
s&i opunei rezisten $a timpul $$, $$$.
xerciiul "P o z i i a d e p l e c a r e l a f e l c a l a e x e r c i i u l - ( f i g .
2H.
Ridicai raul ntins pe lng cap.
Rotarea minii pn ce palma este ndreptat
n 5os, urmat de extensia anteraului. ;oorrea raului lng corp.
(fig.20
Exercitiul 9 (1 ,2,3.
$ndicaii ridicarea raului se face cu cotul
ntins.N a t i m p u l $ $ s c h i m a i p r i z a a e z n d
degetul mare
n palma pacientului, celelalte patru degete pe dosul pal&m e i ,
a 5 u t n d a s t f e l r e a l i z a r e a f l e x i e i m i n i i p e a n t e r a . 0e
repet n ntregime de cte!a ori e xerciiul dup carer e p e t a i
n u m a i t i m p u l 2 i 3 a p l i c n d r e z i s t e n m a n u a l . 4xerciiul
1P o z i i a d e p l e c a r e n t r e d e g e t u l m a r e a l p a c i e n t u l u i i
celelalte # degete aezai cele # degete ale minii. @e&g e t u l
. i. 2 ?
4xerciiul 1 (123+.
@ucei lateral raul pacientului (aducie+ pna
for&meaz cu corpul un unghi de " de grade.Ulexia
anteraului pe ra.4xtensia anteraului pe ra.Re!enire
la poziie iniial (adducie+.$ndicaii 9 n timpul
aduciei i adduciei, cotul tre& uie s fie ntins. ;nd
executai flexia, mna pacientului treuie s ating
umrul. @up Ze exerciiul l poate realiza pacientul n
mod acti! !ei opune rezisten micrilor ae&znd mna
cu palma n sens opus direciei de deplasare a
segmentului pacientului.4 xerciiul 11Poziia de plecare
mna dreapt cuprinde din ex&terior mna pacientului,
degetul mare fiind pe dosul palmei, cealalt mna
cuprinde raul deasupra cotului pe partea interioar
(fig. 22+
=i.
2) 4xerciiul 1#.
=i.
2) 4xerciiul 1#.
=i. 2D
4xerciiul 1) (123#+.
R i d i c a i r a u l s p r e s p a t e c t e s t e p o s i i l ndoii cotul
deasupra capului n t i n d e i c o t u l i r e ! e n i i
l a p o z i i a i n i i a l 4xerciiul 16P o z i i a d e p l e c a r e a p u c a i d e
s u s a r t i c u l a i a r r r i n i i memrului paralizat.)#
=i. 2E ?
4xerciiul 16 (1 23+.
Ulexia anteraului pe ra4xtensia raului pe !erticalR e ! e n i i l a
p o z i i a d e p l e c a r e t r e c n d p r i n t i m p u l 2 . 4xerciiul 1,.Poziia
de plecare ncruci ai degetele am elor
mini palmele orntate n 5os (fig. 2-+.
=i. 2E ?
4xerciiul 16 (123+.
Ulexia anteraului pe ra4xtensia raului pe !erticalRe!enii la poziia de
plecare trecnd prin timpul 2.4xerciiul 1,.Poziia de plecare ncruciai degetele
fig.
2
4xerciiul 1 (123+.
4xtensia raelor cu orientarea palmelor n susU l e x i a r a e l o r c u
orientarea palmelor n 5os.
7.3.1.3. Exerciii cu bastonul de gimnastic din po&iia cucatpe
spate
4xerciiul 1-Pozii de plecarecapete (fig. 2"+. minile cuprind
bastonul la
p.56
.3.2.
4)eriii ative
4xerciii acti!e din poziia ezut pe scaun.S a e z a i n a a
fel nct spatele s fie drept lipit de sptarul
s c a u n u l u i , i a r p i c i o a r e l e s s t e a c u t l p i l e paralele lipite
de podea.4
exerciiul 21. n d o i i i n t i n d e i d e g e t e l e s a u s t r n g e i i
d e s f a c e i pumnul (fig. 32+.
l2
=i. C2
4xerciiul 21 (12+.
Exerciiul 22.
Apropiai degetul mare de fiecare deget al miniiig. 33+.
p.60
l2
=i. CC
4xerciiul 22 (12+.
4xerciiul 23.Palmele fa n fa executai presiuni pe degete
(fig.3#+.
CK
4xerciiul 23.61
l2
=i. CC
4xerciiul 22 (12+.
Exerciiul 23.Palmele fa n fa executai presiuni pe degete (fig.3#+.
CK
Exerciiul 23.
p.61
Fig. 44
x Exerciiu 3/.
executai presiuni pe talpa piciorului4xerciiul 31.Poziia de plecare
o mna st su genunchi, cealalt cuprind\ gama, deasupra gleznei
(fig. #)
+ flexia gamei pe coaps flexia coapsei pe azin flexia gamei pe coaps
extensia genunchiului3
Fig. 44
x Exerciiu 3/.
executai presiuni pe talpa piciorului4xerciiul 31.Poziia de plecare
o mna st su genunchi, cealalt cuprind\ gama, deasupra gleznei
(fig. #)
+ flexia gamei pe coaps flexia coapsei pe azin flexia gamei pe coaps
extensia genunchiului3
Fig. 44
x Exerciiu 3/.
executai presiuni pe talpa piciorului4xerciiul 31.Poziia de plecare
o mna st su genunchi, cealalt cuprind\ gama, deasupra gleznei
(fig. #)
+ flexia gamei pe coaps flexia coapsei pe azin flexia gamei pe coaps
extensia genunchiului3
hiului3
=i. KD ?
4xerciiul 32 (l 2,X
ridicai piciorul spre !ertical aezai piciorul pe pat.
=i. KE
4xerciiul 33.
=i. KD ?
4xerciiul 32 (l 2,X
ridicai piciorul spre !ertical
=i. MH
=ix.
) D , 4 ' e r c i i u l 3 - ( 1 , 2 + .
-.3.2.
4)eriii ative
@up cte!a repetri ncercai toate aceste
m i c r i s e p a r a t c u f i e c a r e p i c i o r, d e c i , f r a 5 u t o r. Q u d u p
rnultt i m p l e ! e i p u t e a e x e c u t a n m o d c u r s i ! i
a p o i c h i a r cu rezisten din partea unei alte
persoane sau aplicndn 5urul gleznei manoane
um plute cu n isip . ;u timp ul !ei putea exersa la
i c i c l e t a e r g o m e t r i c s a u ! e i f a c e exerciii cu gheata
ortopedic i cordon elastic de cauciuc. 0e recomand ca toate
exerciiile, att pentru memrul supe&r i o r c t i p e n t r u c e l
i n f e r i o r s f i e n s o i t e d e e x e r c i i i de respiraie,
deoarece se tie c un creier ine oxigenatf u n c i o n e a z l a
".).
Ridicarea n picioare
s
8a cum ai n!at, ! aezai la marginea pa'ului. Pentru nceput est:9 ne!oie
de acordarea unui a5utor din partea unei alte persoane pentru a ! putea ridica n
picioare. ;nd este ne!oie numai de puin :a5utor, persoana care !i&1 acord se aaz
de partea paralizat i cu mna sting apuc raul drept su axil. Na comanda dat
pentru ridicare, aplecai uor trunchiul n fa i concomi&tent cu ducerea umerilor
spre nainte executai mpingerea n picioare n timp ce a5utorul @&str ! susine
de su ra i trage puin n sus.@ac se impune acordarea unui a5utor mai mare
atunci, cel ce&1 acord se aaz n faa pacientului fixnd genun&chiul drept n faa
genunchiului sntos al acestuia. 8puc pacientul cu amele rae n 5urul taliei i l
trage nainte i n sus n timp ce, cu genunchiul exe&cut o presiune asupra
genunchiului pacientului. Pacien&tul se spri5in cu mna sntoas de umrul celui
cc&i acord a5utorul. ;u timpul ridicarea n picioare se poate realiza fr a5utor i
asta la un inter!al foarte scurt.0tai cu picioarele uor deprtate i tlpile paralele
lipite de podea. /na paralizat st pe lng corp sau pe genunchi, mna sntoas se
fixeaz pe genunchiul sntos. 8plecarea trunchiului n fa, concomitent cu
mpingerea n picioare i ducerea umerilor nainte snt micrile pe care treuie f le
executai pentru a reui s ! ridicai singur.
".6. 8ezarea pe scaunS aezai n faa scaunului cu picioarele deprtate la ni!
elul umerilor. 8plecai mult trunchiul nainte,-#