Caiet Practica NEURO USH Sidenco Recuperare in Hemiplegie Hemiplegici

Recuperare in hemiplegie hemiplegici
Objective To compare home-based cardiac rehabilitation (CR) with usual care

(control group with no rehabilitation) in elderly patients who declined participation
in centre-based CR.
Design Randomised clinical trial with 12months follow-up and mortality data
after 5.5years (mean follow-up 4years).
Setting Rehabilitation unit, Department of Cardiology, Copenhagen,
Denmark.
Participants Elderly patients 65years with coronary heart disease.
Intervention A physiotherapist made home visits in order to develop an
individualised exercise programme that could be performed at home and
surrounding outdoor area. Risk factor intervention, medical adjustment, physical
and psychological assessments were offered at baseline and after 3, 6 and 12
months.
Main outcome measurements The primary outcome was 6min walk test
(6MWT). Secondary outcomes were blood pressure, body composition, cholesterol
profile, cessation of smoking, health-related quality of life (HRQoL), anxiety and
depression.
Results 40 patients participated. The study population was characterised by
high age (median age 77years, range 6592years) and high level of comorbidity.
Patients receiving home-based CR had a significant increase in the primary
outcome 6MWT of 33.5m (95 CI: 6.2 to 60.8, p=0.02) at 3months, whereas the
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.
BMJ Open 2012;2:e001820 doi:10.1136/bmjopen-2012-001820
Cardiovascular medicine
Home-based cardiac rehabilitation is an attractive alternative to no

cardiac rehabilitation for elderly patients with coronary heart disease: results
from a randomised clinical trial
1.
Bodil Oerkild,
2.
Marianne Frederiksen,
3.
Jorgen Fischer Hansen,
4.
Eva Prescott
+Author Affiliations
1.
Department of Cardiology, Bispebjerg University
Hospital, Copenhagen, Denmark
Correspondence to
1.
Bodil Oerkild; Oerkild@dadlnet.dk
Received 12 November 2012
Revised 12 November 2012
Accepted 22 November 2012
Published 18 December 2012

Abstract
Objective To compare home-based cardiac rehabilitation (CR) with usual care
(control group with no rehabilitation) in elderly patients who declined participation
in centre-based CR.
Design Randomised clinical trial with 12months follow-up and mortality data
after 5.5years (mean follow-up 4years).
Setting Rehabilitation unit, Department of Cardiology, Copenhagen,
Denmark.
Participants Elderly patients 65years with coronary heart disease.
Intervention A physiotherapist made home visits in order to develop an
individualised exercise programme that could be performed at home and
surrounding outdoor area. Risk factor intervention, medical adjustment, physical
and psychological assessments were offered at baseline and after 3, 6 and 12
months.
Main outcome measurements The primary outcome was 6min walk test
(6MWT). Secondary outcomes were blood pressure, body composition, cholesterol
profile, cessation of smoking, health-related quality of life (HRQoL), anxiety and
depression.
Results 40 patients participated. The study population was characterised by
high age (median age 77years, range 6592years) and high level of comorbidity.
Patients receiving home-based CR had a significant increase in the primary
outcome 6MWT of 33.5m (95 CI: 6.2 to 60.8, p=0.02) at 3months, whereas the
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
To compare home-based cardiac rehabilitation with usual care in elderly

patients with coronary heart disease who decline participation in a centre-based
rehabilitation programme.
Key messages
Home-based cardiac rehabilitation improved exercise capacity among

elderly patients with coronary heart disease.
This population of elderly patient had a high level of comorbidity and
disability.
When the home-based intervention ceased, the effect was rapidly lost.
Strengths and limitations of the study
The randomised design provides a higher level of evidence.
This population represents the real-world scenario of elderly cardiac
patients.
The duration of the intervention may be too short to maintain changes in
exercise capacity at 12months of follow-up.
The size of the study did not allow subgroup analysis.
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.
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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
alternative encouraged to participate in the centre-based CR programme (outside

the study). Patients who declined participation in these offers were invited to
participate in this study.
The recruitment period was from January 2007 to July 2008.
Inclusion of patients was not based on a sample size calculation.
Patients had to give informed consent before any trial-related procedures.
Patients were randomised in alternated block sizes of 46 using computer-generated
randomly permuted blocks. An impartial person, not related to the study,
randomised the patients. Because of the nature of the intervention, concealment of
randomisation was not feasible with regard to both patients and researcher. Data
were collected at Bispebjerg University Hospital before randomisation and after 3, 6
and 12months. In addition, overall mortality data were obtained in July 2012, 5.5
years after the study was initiated.
The study was approved by the local ethic committee (jr.nr.KF01327990), the
Danish Data Protection Agency (j.nr. 2006-41-7212) and is registered
at http://www.clinicaltrial.gov(NCT00489801).
Intervention
The home programme
Patients received two home visits by a physiotherapist in a 6-week interval
with the purpose of creating a training programme that could be performed at home
and outside in local surroundings. Patients were carefully instructed in the training
programme and guided to optimal training effort. In between the visits, a telephone
call was made by the physiotherapist to resolve any questions.
The exercise programmes were individualised but followed the international
recommendations with 30min exercise/day including 510min warm up (eg, slow
walking) and 10min. cool down at a frequency of 6days/week14 ,15 at an intensity
of 1113 on the Borg scale.15 For very disabled patients, the exercise programmes
were of shorter duration but then repeated several times a day.
Regarding risk factor intervention and medical adjustment, the patients
consulted a cardiologist at baseline and after 3, 6 and 12months. At 4 and 5months,
a telephone call was made by the cardiologist to encourage continuous exercising
and to answer any medical questions. All patients were offered dietary counselling
and, if required, smoking cessation.
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.
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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).
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Table 2
Effect of intervention at 3months follow-up
View this table:
Table 3
Follow-up data at 12months
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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,
they both found a sustained improvement in exercise capacity after 12months, if

the exercise programme was initiated at home. The discrepancy could be caused by
the duration of our home intervention that may have been too short to maintain
changes in lifestyle at 12months follow-up, but our home intervention is in line
with other home-based programmes.12 ,13 The majority of programmes have a
duration of 612weeks.7 ,9 ,1113 It has been suggested that more intensive
programmes with prolonged duration beyond 12weeks have a more successful
long-term outcome.19 ,20 However, in a previous study of heart failure
patients,21 even a prolonged centre-based maintenance programme with supervised
sessions every 2weeks, in addition to home exercise training, could not maintain
the improvements achieved during initial CR.21 Furthermore, in the very large HFACTION trial,22 patients participated in an initial centre-based exercise programme
of 36 sessions in 3months followed by a home-based exercise programme with
intensive follow-up and equipment for home training was provided. In the HFACTION trial22 there were no changes in exercise capacity at 12months followup. This was explained partly by insufficient adherence to training that was below
the target set at all time points. The HF-ACTION trial mainly included middle-aged
men with no major comorbidities or limitations that could interfere with training.
Thus, in spite of intensive exercise programmes with close follow-up in patients
with no significant concomitant comorbidities, it is difficult to motivate patients to
adhere to training. Feasible solutions to overcome this have not yet been identified.
The discrepancy between studies may also be due to the differences in the
enrolled populations. Our population was significantly older (mean age 77.36.0 vs
69.09.0years3 and 64.30.5years18) and had a high degree of comorbidity and
low level of exercise capacity. Age, comorbidity and disability are all found to be
negatively correlated with physical activity15 ,23and adherence to
training6 ,24 ,25 and thus may have contributed significantly to the lack of
sustained effect at 12months. Moreover, in the only other study targeting the
elderly,3 the population was highly selected with exclusion rate of 72 among the
very old patients (>75years) due to comorbidity, disability and congestive heart
failure, leading to a much healthier population, compared to our population in
which only 10 were excluded.
Coronary heart disease is one of the leading causes of disability and, with
increasing age, other chronic non-cardiac conditions further limit function.26 Our
population of elderly had a very high frequency of comorbid conditions (57 had
CMI3). For comparison, a recent very large nationwide study, including 234000
patients (median age 68years in men and 75years in women) with first time acute
MI, found that only 6 of that population had CMI3.27 In addition to the high
frequency of comorbidity, we found a low level of exercise capacity at baseline,
with mean 6MWT=308.4m120. In healthy elderly subjects, mean 6MWT is found

to be approximately 659m74m28 and, in a recent RCT study from our group
comparing home-based CR with centre-based CR10 a baseline mean 6MWT of 340
m122m in the centre group was found.10 These characteristics indicate that the
group of elderly patients who decline participation in centre-based rehabilitation is
very vulnerable and not necessarily comparable with the population who accept
centre-based CR. Our finding is in concordance with previous studies who found
that older age, high burden of comorbidity and low level of exercise capacity was
negatively correlated with participation rate in centre-based CR programmes.6 ,24
The high burden of comorbidity in this population is most likely explained by
the computerised identification of patients which eliminated the selection and
referral bias often seen in rehabilitation units, which is not in favour of the elderly
and patients with comorbidity.24 ,2931
Other outcomes
Self-reported active lifestyle and systolic blood pressure changed favourably
in the home group after the intervention but there were no significant differences in
diastolic blood pressure, body composition, cessation of smoking, cholesterol
profile and HRQoL between the groups. Our population had a favorable
cardiovascular risk factor control and low anxiety and depression score (HADS
score <8 is within normal rage)32 ,33 at entrance to the study why a further
improvement could not be expected.
We did not find any significant changes in HRQoL measured by SF-12. This
is partly due to lack of statistical power and the limited duration of our home
intervention but is in concordance with the meta-analysis by Jolly et al12 and with a
recent published review concerning CR and HRQoL.34 We did not have any
specific psychological intervention but the type of intervention (comprehensive
programmes, exercise only or mainly psychological interventions) do not seem to
affect these results.12 ,34
In central Europe, centre-based CR is the traditional choice of CR services.
However, establishing of home-based CR programmes as an alternative for elderly
patients could improve CR attendance rate. In English-speaking countries and in
countries where health services are not free, home-base CR programmes are more
commonly used, primarily through the adoption of The Heart Manual.35 ,36 This is
currently not an option in non-English-speaking countries, in many of which there
is a stronger tradition of centre-based CR.
In the everyday scenario at the rehabilitation units, there is only one CR
programme available, and this is often a centre-based programme. Patients who
decline enrolment in these programmes do not have alternatives. A total of 29 of
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
Contributors BO designed and initiated the study, collected the data,

wrote the statistical analysis plan, analysed the data and drafted and revised the
paper. She is guarantor. EP contributed with design, wrote the statistical analysis
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.
Funding This work was supported by VELUX FOUNDATION.
Competing interests None.
Patient consent Obtained.
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).
Provenance and peer review Not commissioned, externally peer

reviewed.
Data sharing statement No additional data are available.

This is an open-access article distributed under the terms of the Creative
Commons Attribution Non-commercial License, which permits use, distribution,
and reproduction in any medium, provided the original work is properly cited, the
use is non commercial and is otherwise in compliance with the license.
See: http://creativecommons.org/licenses/by-nc/2.0/ an
dhttp://creativecommons.org/licenses/by-nc/2.0/legalcode.
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5.2. Exerciii pentru reeducarea mersului

Mersul constituie una din cele mai obinuite micri executate de
om n scopul deplasrii care, dei este de o deosebit complexitate, se
realizeaz cu un consum relativ mic de energie, bazat ns pe o coordonare
nervoas perfect a micrilor membrelor superioare i inferioare
precum i ale corpului.
Pentru a se deplasa, hemiplegicul folosete la maximum forele
musculare restante, ceea ce atrage dup sine modificarea n totalitate a
structurii pasului. n general hemiplegicul are o atitudine particular
caracterizat prin poziia capului uor aplecat nainte, privirea ndreptat
n jos, umrul czut, braul afectat lipit de corp, cotul flexat cu mna n
uoar pronaie i degetele flexate. Membrul inferior paralizat este

proiectat nainte printr-o micare de balans a bazinului, se menine rigid i
34
Capitolul IV
Programul de recuperare funcional a bolnavilor hemiplegici
4.1. Programul de kinetoterapie
4.1.1. Exerciii fizice la pat
Recuperarea neuromotorie a bolnavului hemiplegic parcurge dou
etape distincte: akinetic i kinetic.
Perioada akinetic este perioada postacut cnd pacientul este, nc
un risc vital; n aceast perioad obiectivele terapeutice recuperatorii se
rezum numai la prevenirea redorilor articulare i a contracturilor
musculare ambele capabile s perturbe reluarea motilitii active. n acest
cadru de evoluie a bolii primul lucru ce trebuie realizat este posturarea n
anumite poziii impuse care, ulterior, s permit pacientului s-i
redobndeasc propriul su control. Aceste imobilizri artificiale ale
segmentelor
plegice vor fi prezente n fazele incipiente ale bolii pe durate de
cteva minute la cteva ore pe zi, pe msur ce starea general permite,
rrind numrul pauzelor i mrind durata de posturare (este indicat ca
schimbarea posturilor s fie fcut ct mai frecvent).
Posturarea n decubit dorsal se face cu gtul i trunchiul n extensie
folosindu-se, de regul un sul mic sub ceaf. Membrul superior va fi n
extensie, cu palma fixat n pronaie i degetele n extensie, cu ajutorul
unui scule cu nisip. Prevenirea rotaiei externe a coapsei se poate realiza
tot cu ajutorul unui scule cu nisip aezat la nivelul genunchiului.
Posturarea n decubit ventral se face totdeauna cu membrul
superior n abducie ceva peste 90 F 0
B 0, avnd cotul n flexie cu antebraul n
pronaie innd un sul n mn.
Posturarea n decubit lateral se realizeaz numai pe partea
sntoas, cu braul meninut n uoar abducie cu ajutorul unei pernue
16
naintarea s se relizeze prin ducerea alternativ a unui picior
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.
Exerciii premergtoare mersului

Toa t e Exerciiil e p r e m e r g t o a r e m e r s u l u i ( f i g u r i l e )
# 61+ se !or efectua cu mna sntoas spri5init la arfix (spalier+, ca
n fig. )-. @ i n l a t e r a l s p r i 5 i n l a a r f i x c u m n a
s n t o a s , picioarele uor deprtate (fig. )#+.4xerciiul 3" ridicare pe !
rfuri (1+ i re!enire (2+4xerciiul # G ridicarea alternati! a !
rfurilor Eun picior sespri5in pe toat talpa, celDalt se spri5in pe calci+
(fig. ))+.4xerciiul #1.
ridicarea alternati! pe !rful unui picior (fig. )

6 + . 4xerciiul #2. mutarea greutii de pe un picior pe cellalt
(fig. )+.4xerciiul #3. ndoirea genunchilor (genoflexiuni+ (fig. )-+
89
f
:
g
. )# G 4xerciiul 3" (1 2+.
S
)) G 4xerciiul #.
=i.
)6 4xerciiul #1
9'
:2
f:g. ) 4xerciiul #2 (1 2+.
=i.
)0 4xerciiul #3.
"1
4xerciiul ##.
alansarea unui picior nainte i napoi (fig. )"+.4xerciiul #). alansri

laterale (fig. 6+.
,##,
:-?2s&s$3iF 3s*. 1
.Uig.
DH
4xerciiul #) (12+.
9&
ig. )" 4xerciiul ## (12+.
4xerciiul ##.

alansarea unui picior nainte i napoi (fig. )"+.4xerciiul
#). alansri laterale (fig. 6+.
,##,
:-?2s&s$3iF 3s*.1
.Uig.
DH
4xerciiul #) (12+.
9&
ig. )" 4xerciiul ## (1 2+.
Indicaii 9 tendina este ca flexia genunchiului s se execute concomitent cu

flexia coapsei pe azin deoarece inter!ine automatismul cunoscut su numele de
triplafle&xie a memrului inferior. Jreuie explicat olna!ului c acestea snt dou
faze ale unei micri ce se execut suc&cesi!. Prin flexia genunchiului, gama
treuie s fie pa&ralel sau aproape paralel cu solul n timp ce coapsa este
perpendicular sau chiar olic pe sol adic n uoar extensie pe azin. 8ceasta este
micarea exagerat, dar la nceput pentru a putea fi simit i neleas treuie

ececutat n acest fel. ;nd se execut flexia coapsei pe azin s nu se permit
ridicarea oldului. Pentru aceasta este ine s ! aezai n spatele pacientului s
punei minile pe oldurile acestuia i s executai, uoar presiune n 5os.1.#.
Reeducarea mersului
Pentru a uura mersul hemiplegicului este ine ca acesta s fie nclat cu o
gheat care s&i fixeze ine glezna deoarece piciorul are tendina s se rsuceasc
spre interior. Na primele ncercri de mers pacientul este dominat de team fapt
ce&1 determin s fie crispat. 4l treuie ncura5at i spri5init s poat pi. naintea
pri&mu'ui pas nu uitai s&i corectai poziia corpului care treuie s fie cu capul
sus, pri!irea nainte, spatele drept i memrul superior paralizat ct mai relaxat pe
lng corp. Pentru a oine aceast relaxare putei aplica uoare tapotri deasupra
cotului pe partea posterioar. Jotdea&una primul pas s fie executat cu mpmrul
paralizat. Uoarte mult atenie treuie acordat timpului de spri5in unilateral pe
memrul sntos, cnd memrul paralizat de!ine pen&du'ant. n mersul normal
memrul pendula]t se ex&
p.94
accidentele vasculare centrale
Acestea pot fi:
* accidente vasculare hemoragice, care sunt produse de ruperea unui vas de
snge pe fondul hipertensiunii arteriale sau de ruperea unui anevrism congenital.
Hemoragia central debuteaz brusc, cu dureri de cap, vom, delir, pierderea
cunotinei i instalarea deficitului motor.
* accidente vasculare ischemice. Ischemia cerebral este produs de
ntreruperea circulaiei sanguine n arterele intra sau extra craniene. Aceast
obstrucie poate fi produs de plcile aterosclerotice sau de alte boli (arterita, boal
reumatic a inimii)
Simptomele se dezvolt rapid i pot fi diferite n funcie de localizarea
ocluziei vasculare.
2. hemiplegii datorate compresiunii cerebrale

Acestea sunt datorate formatiunilor tumorale iar evoluia este n general lent.
Tumorile pot fi benigne sau maligne (canceroase). Evoluia pacientului va fi, n cele
mai multe dintre cazuri, n concordan cu tipul formatiunii tumorale.
3. hemiplegii datorate traumatismelor cranio cerebrale
Cauzele acestor traumatisme pot fi numeroase: accidente rutiere, cderi,
agresiuni, accidente de sport, accidente domestice, plgi produse de urme de foc
etc.
n afar de pierderea capacitii de micare i a tulburrilor de sensibilitate,
hemiplegiile mai pot fi nsoite de: afazie, tulburri psihice, tulburri de echilibru.
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:
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.
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.
Scopul acestui nivel va fi de a invata bolnavul catre auto deservire.

Masurile de baza a reabilitarii sint:
1. Kinetoterapia
2. Psihoterapia
Restabilirea functiilor corticale superioare
3. Terapia prin munca
4. Tratamentul medicamentos
5. Fizioterapia
Durata perioadei acute este determinata regresul procesului de dislocare si
edem cerebral. In ictus hemoragic durata 1,5 - 6 sapt. In ictus iscemic 1 -4 sapt.
In aceasta perioada se intreprind masuri pentru a salva viata pacientului si a
stabiliza functiile vitale.
Masurile de recuperare se incep cit mai precoce, dar dupa stabilizarea
bolnavului. Reabilitarea pasiva ce include kinetoterapia, masajul, gimnastica pasiva,
respiratorie se incepe din primele zile.
Reabilitarea activa este strict individuala si depinde de caracterul accidentului
vascular cerebral.
Kinetoterapia - se indeplineste sub forma de gimnastica curativa, elementele
careia sint:
1. pozitiile anumite (posturile)
2. miscarile pasive
3. gimnastica respiratorie
4. privirea fixata si motilitatea oculara
5. masajul
Trebuia de tinut cont de cresterea treptata a activitatilor si preintimpinarea
oboselii.
I.Tratarea prin pozitie
Tratarea prin pozitii de gimnastica pasiva se incepe in:
* ictus ischemic - la 2-4 zi
* ictus hemoragic - la 6-8 zi in conditii de hemodinamica stabila.
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. Pozitia pe spate
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. Pozitia pe partea paretica
Capul se stabilizeaza in pozitia comoda, trunchiul putin intors si se mentine
din spate si picioare cu perne.
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 Pozitie pe partea sanatoasa
Capul ocupa o pozitie pe o linie cu trunchiul, trunchiul usor flectat anterior.
Mina paretica se aranjeaza pe perna, flectata in articulatie umarului sub un unghi de
90grd si intinsa.
Piciorul paretic usor flectat in articulatia coxofemurala si articulatia
genunchiului, gamba si planta sint plasate 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 extensia capsulei articulare - ce apare destul de
frecvent si este insotita de aparitia durerilor.
II.Miscarile pasive.
Amelioreaza circulatia in membrele paretice, contribue la scaderea tonusului
muscular, precum si stimuleaza aparitia miscarilor active datorita influentei
impulsurilor aferente ce apare in muschii si articulatiile membrelor paralizate.
Pentru a diminua hipertonusul muscular si preintimpinarea aparitiei

schineziilor musculare mobilizarile pasive se incep din articulatiile mari ale
membrelor, treptat trecind la cele mici.
Miscarile pasive se fac atit pe partea bolnava cat si pe cea sanatoasa cu un
tempo lent (tempo-ul rapid mareste tonusul muscular). Pentru acasta metodistul cu
o mana apuca extremitatea mai sus de articulatie, cu alta mai jos, facand apoi
miscari in aceasta articulatie.
In fiecare articulatie se fac 5-10 miscari. Miscarile pasive se asociaza cu
gimnastica respiratorie si invatarea bolnavului in relaxarea activa a muschilor.
III.Miscarile active
In lipsa contraindicatiilor se incep:
- ictus hemoragic -la 15-20 zi
- ictus ischemic-la 7-10 zi de boala.
Cerinta de baza - dozarea stricta a sarcinii si cresterea ei treptata.
Se disting exercitii cu caracter static, in care are loc contractia tonica a
muschilor si exercitii cu caracter dinamic (efectuarea miscarilor). In pareze severe
gimnastica activa se incepe cu exercitii cu caracter static ca fiind mai usoare. Aceste
exercitii, constau in mentinerea segmentelor membrelor in pozitia data (de
kinetoterapeut).
Exercitiile cu caractre dinamic se efectueaza in primul rand pentru muschii ai
caror tonus deobicei nu se mareste: m. abductori ai umarului, supinatori, extensorii
bratului, mainii, degetelor, m. abductori ai coapsei, flexorii gambei si plantei.
In pareze profunde se incepe cu exercitii ideomotorii (bolnavul la inceput
trebuie sa-si imagineze singur exercitiile date, iar apoi sa le efectueze, comentandule verbal) si exercitii in conditii necomplicate. Aceste conditii constau in inlaturarea
fortei de greutate, si fortei de frecare ce complica efectuarea exercitiilor. Pentru
aceasta, miscarile se fac pe o suprafata orizontala, neteda, cu ajutorul metodistului
care mentine segmentele membrelor mai jos sau mai sus fata de articulatia in
miscare.
O importanta mare se acorda miscarilor izolate in articulatii. Petru aceasta

se foloseste procedeul de opunere miscarii active, ce permite metodistului de a regla
sarcina in diferite grupe de muschi. Trebuie urmarita respiratia (nu se permite
retinerea respiratiei), extinderea m. hipertonici la inspiratie. Se efectuiaza toate
miscarile posibile petru aceasta articulatie cu un tempo lent. La baza formarii
deprinderilor motorii sta formarea unor legaturi intre diferitii analizatori corticali, si
atunci la gimnastica curativa se folosesc diferite forme de aferentatii (stimulatia
proprio- si exteroreceptorilor).
Spre sfirsitul perioadei acute a bolii se complica si caracterul miscarilor
active, frecventa repetarii lor, se incep exercitii si pentru trunchi (intoarceri si
inclinari laterale, flexie, extensie.)
Incepind cu a 8-10 zi in ictus ischemic si de la 3-4 sapt. in ictus
hemoragic daca permite starea generala a bolnavului si hemodinamica, bolnavul se
invata a sedea. La inceput bolnavului de 1-4 ori pe zi pe durata de 3-5 min. i se da o
pozitie semisezanda sub un unghi de 30grd. In decurs de citeva zile sub controlul
pulsului se mareste unghiul si durata. Accelerarea pulsului la schimbarea pozitiei nu
trebuie sa depaseasca 20 b./min.,la aparitia unei tahicardii evidente se micsoreaza
unghiul de asezare si durata procesului.
Peste 6 zile unghiul de ridicare se mareste pina la 90grd, iar durata - pina la 15
min. apoi se invata asezarea cu picioarele coborite (mina paretica se fixeaza pentru
a preintimpina extinderea capsulei articulare a umarului.
In timpul asezarii piciorului sanatos periodic se aranjeaza pe cel bolnav
pentru a repartiza masa corpului pe partea paretica.
Se trece la pozitia in picioare linga pat pe ambele picioare si alternand un
picior cu altul (fixind articulatia genunchiului pe partea paretica cu ajutorul
langetei),mersul pe loc, apoi pe mersul prin salon, coridor cu ajutorul metodistului,
iar pe masura imbunatatirii mersului - cu ajutorul cirjelor.
Este important de a elabora un steriotip corect al mersului, care consta in
flexia concomitenta a piciorului in articulatia flexo-femurala , genunchiului ,
talocrurala. Ultima etapa este mersul pe scari . mana paretica trebuie sa fie fixata.
IV MASAJUL
Masajul, in lipsa contraindicatiilor, se incepe:

- in ictus ischemic - la 2-4 zi de boala
- in ictus hemoragic - la 6-8 zi de boala.
Masajul se face in pozitia bolnavului culcat pe spate si partea sanatoasa,
zilnic, incepind cu durata de 10 min. si treptat se mareste durata pina la 20 min.
Masajul muschilor poate influenta starea tonusului muscular: in pareze spastice
stimularea energica a tesuturilor duce la cresterea spasticitatii. Marirea spasticitatii
poate fi cauzate si de tempo-ul miscarilor ( semnul lent scade tonusul muscular).
Deoarece in hemiplegie este o hipertonie selectiva, masajul trebuie sa fie tot
selectiv.
La efectuarea masajului pentru muschii hipertonici se face netezirea,
frictiunea circulara si vibratia neintrerupta. La masarea muschilor antagonisti se
foloseste netezirea, frictiunea si vibratia intrerupta.
Masajul se incepe de la segmentele proximale si continue spre cele distale a
membrelor. Atentie la masarea m. pectoral mare cu tonus marit (se face netezire
lenta), si m. deltoid - cu tonus scazut (se face masaj stimulant).
Masajul se face timp indelungat - 30-40 de proceduri.
Durata masurilor de reabilitare in stationar nu dureaza mai mult de 1,5-2 luni.
Ulterior bolnavul se transfera la centre de reabilitare ambulatorii.
Bibliografie:
British Medical Journal, 11/1998, London Bucharest
Tudor Sbenghe Recuperarea medical la domiciliul bolnavului, Editura
Medicala 1996, Bucuresti
>>>>>>>>>>>>
Exercitii pentru acasa in hemiplegie
05 mai 2010 by Diana Cicirean
Hemiplegia cauzata de accidente vasculare cerebrale datorita hipertensiunii

arteriale sau aterosclerozei. Afectarea motorie sau senzoriala este prezenta la
membrele de pe o singura parte si este insotita de deviatii ale ochilor si gurii.
Recuperarea hemiplegiilor pas cu pas
Recuperarea va incepe cu o posturare a in pat pentru evitarea aparitiei
pozitiilor neadecvate, a durerilor si a escarelor la nivelul suprafetelor de contact.
Initial se efectueaza miscari pasive, exercitii de reluare a pozitiei sezand si a
ortostatismului si mersului. Recuperarea este de lunga durata si trebuie efectuata si
acasa, sprijinul familiei avand o importanta majora.
Iata cateva miscari active pe care puteti sa le efectuati acasa la indicatia
medicului.
Gimnastica activa se incepe cu exercitii statice sau exercitii de posturare

a diferitelor segmente ale corpului.
Exercitiile active se efectueaza pentru mobilizarea articulara si

mentinerea tonusului normal al musculaturii. Aceste exercitii sunt pentru
musculatura umarului, extensorii si supinatori ai bratului, musculatura mainii si
degetelor. Pentru munsculatura membrului inferior, efectuam exercitii pentru
coapsa, gamba si talpa piciorului.
Dupa o luna de la accidentul vascular se incepe recuperarea din pozitia

sezand. La inceput se va sta in sezut de 3-4 ori pe zi timp de cateva minute. Se
incepe progresiv de la o pozitie semisezanda iar in decurs de citeva zile se mareste
unghiul si durata.
Pulsul trebuie monitorizat in permanentaatat la schimbarea pozitiei cat si

in timpul mobilizarilor, pulsul nu trebuie sa depaseasca 20 b./min.

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.
Treptat se trece la pozitia stand linga pat pe ambele picioare si alternand

un picior cu altul. Iar de aici se vor incepe miscarile de mers pe loc, dup care cel
individual.
In ultima etapa se va redobandi echilibrul si mobilitatea pentru a merge

pe scarim initial cu sprijin si dupa individual.
Alte articole:
Recuperarea medicala in hemiplegie
5 pasi pentru masajul in hemiplegie
>>>>>>>>>
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
extensia capsulei articulare ce apare destul de frecvent si este insotita de aparitia

durerilor.
Miscarile pasive
Amelioreaza circulatia in membrele paretice, contribuie la scaderea tonusului
muscular, stimuleaza aparitia miscarilor active datorita influentei impulsurilor
aferente ce apare in muschii si articulatiile membrelor paralizate.
Pentru a diminua hipertonusul muscular si preintimpinarea aparitiei
schineziilor musculare mobilizarile pasive se incep din articulatiile mari ale
membrelor, treptat trecind la cele mici.
Miscarile pasive se fac atit pe partea bolnava cat si pe cea sanatoasa cu un
ritm lent (ritmul rapid mareste tonusul muscular).
Pe fiecare articulatie se fac 5-10 miscari. Miscarile pasive se asociaza cu
gimnastica respiratorie si invatarea bolnavului u crelaxarea activa a muschilor.
Miscarile active
Se disting exercitii statice, in care are loc contractia tonica a muschilor si
exercitii dinamice. In pareze severe gimnastica activa se incepe cu exercitii cu
statice ca fiind mai usoare. Aceste exercitii, constau in mentinerea segmentelor
membrelor in pozitia data de kinetoterapeut.
Exercitiile dinamice se efectueaza in primul rand pentru muschii ai caror
tonus deobicei nu se mareste: m. abductori ai umarului, supinatori, extensorii
bratului, mainii, degetelor, m. abductori ai coapsei, flexorii gambei si plantei.
In parezele profunde se incepe cu exercitii ideomotorii (bolnavul la inceput
trebuie sa-si imagineze singur exercitiile date, iar apoi sa le efectueze, comentandule verbal) si exercitii in conditii necomplicate. Aceste conditii constau in inlaturarea
fortei de greutate, si fortei de frecare ce complica efectuarea exercitiilor. Pentru
aceasta, miscarile se fac pe o suprafata orizontala, neteda, cu ajutorul metodistului
care mentine segmentele membrelor mai jos sau mai sus fata de articulatia in
miscare.
O importanta mare se acorda miscarilor izolate in articulatii. Petru aceasta se
foloseste procedeul de opunere miscarii active, ce permite kinetoterapeutului sa
regleze sarcina in diferite grupe musculare. Trebuie urmarita respiratia (nu se
permite retinerea respiratiei), extinderea m. hipertonici la inspiratie. Se efectuiaza
toate miscarile posibile petru aceasta articulatie cu un tempo lent. La baza formarii
deprinderilor motorii sta formarea unor legaturi intre diferitii analizatori corticali.
Spre sfirsitul perioadei acute a bolii se complica si caracterul miscarilor active

si frecventa repetarii lor si se incep exercitii pentru trunchi (intoarceri si inclinari
laterale, flexie, extensie.)
Incepind cu a 8-10 zi, daca permite starea generala a bolnavului si
hemodinamica, bolnavul este invatat sa stea in asezat. La inceput pozitia se mentine
3-5 min. si se face de 1-4 ori pe zi. In decurs de citeva zile sub controlul pulsului se
mareste unghiul si durata. Accelerarea pulsului la schimbarea pozitiei nu trebuie sa
depaseasca 20 b./min.,l a aparitia unei tahicardii evidente se micsoreaza unghiul de
asezare si durata procesului.
Peste 6 zile unghiul de ridicare se mareste pina la 90grd, iar durata pina la
15 min. apoi se invata asezarea cu picioarele coborite, mina paretica se fixeaza
pentru a preintimpina extinderea capsulei articulare a umarului.
Se trece la pozitia stand linga pat pe ambele picioare si apoi alternand un
picior cu altul (fixind articulatia genunchiului pe partea paretica cu ajutorul ortezei),
mersul pe loc, mersul prin salon, coridor cu ajutorul recuperatorului, iar pe masura
imbunatatirii mersului cu ajutorul cirjelor.
Este important de a elabora un steriotip corect al mersului, care consta in
flexia concomitenta a piciorului in articulatia flexo-femurala , genunchiului ,
talocrurala.
Ultima etapa este mersul pe scari, mana paretica trebuie sa fie fixata.
Masajul
Masajul se face din culcat pe spate si pe partea sanatoasa, zilnic, incepind cu
durata de 10 min. si treptat se mareste durata pina la 20 min. Masajul muschilor
poate influenta starea tonusului muscular: in pareze spastice stimularea energica a
tesuturilor duce la cresterea spasticitatii. Marirea spasticitatii poate fi cauzata si de
tempo-ul miscarilor.
Masajul pentru muschii hipertonici cuprinde manevre de netezire, frictiune
circulara si vibratii neintrerupte.
Masarea muschilor antagonisti se face prin neteziri, frictiuni si vibratii
intrerupte.
Masajul se incepe de la segmentele proximale si continua spre cele distale ale
membrelor. Atentie la masarea m. pectoral mare cu tonus marit (se face netezire
lenta) si m. deltoid cu tonus scazut (se face masaj stimulant).
Exercitii pentru acasa in hemiplegie

05 mai 2010 by Diana Cicirean
Hemiplegia cauzata de accidente vasculare

cerebrale datorita hipertensiunii arteriale sau aterosclerozei. Afectarea motorie sau
senzoriala este prezenta la membrele de pe o singura parte si este insotita de deviatii
ale ochilor si gurii.
Recuperarea hemiplegiilor pas cu pas
Recuperarea va incepe cu o posturare a in pat pentru evitarea aparitiei pozitiilor
neadecvate, a durerilor si a escarelor la nivelul suprafetelor de contact.
Initial se efectueaza miscari pasive, exercitii de reluare a pozitiei sezand si a
ortostatismului si mersului. Recuperarea este de lunga durata si trebuie efectuata si
acasa, sprijinul familiei avand o importanta majora.
Iata cateva miscari active pe care puteti sa le efectuati acasa la indicatia
medicului.
Gimnastica activa se incepe cu exercitii statice sau exercitii de posturare a
diferitelor segmente ale corpului.
Exercitiile active se efectueaza pentru mobilizarea articulara si mentinerea
tonusului normal al musculaturii. Aceste exercitii sunt pentru musculatura umarului,
extensorii si supinatori ai bratului, musculatura mainii si degetelor. Pentru
munsculatura membrului inferior, efectuam exercitii pentru coapsa, gamba si talpa
piciorului.
Dupa o luna de la accidentul vascular se incepe recuperarea din pozitia
sezand. La inceput se va sta in sezut de 3-4 ori pe zi timp de cateva minute. Se
incepe progresiv de la o pozitie semisezanda iar in decurs de citeva zile se mareste
unghiul si durata.
Pulsul trebuie monitorizat in permanentaatat la schimbarea pozitiei cat si in
timpul mobilizarilor, pulsul nu trebuie sa depaseasca 20 b./min.
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.
Treptat se trece la pozitia stand linga pat pe ambele picioare si alternand un

picior cu altul. Iar de aici se vor incepe miscarile de mers pe loc, dup care cel
individual.
In ultima etapa se va redobandi echilibrul si mobilitatea pentru a merge pe
scarim initial cu sprijin si dupa individual.
Alte articole:
Recuperarea medicala in hemiplegie
5 pasi pentru masajul in hemiplegie
ELENA CRISTEA
Exercitii de Gimnastica Recuperatorie la Hemiplegici
E X E R C I I I
D E
G I M N A S T I C
R E C U P E R A T O R I E LA H E M I P L E G I C I
ELENA CRISTEA
EDITURA MEDICALA BUCURETI 1984
https://www.scribd.com/doc/218399528/127371005-ELENA-CRISTEA-Exercitii-de-Gimnastica-RecuperatorieLa-Hemiplegici-1
PROGRAM KINETIC PRNTRU BOLNAVUL HEMIPLEGIC
https://www.scribd.com/doc/218399528/127371005-ELENA-CRISTEAExercitii-de-Gimnastica-Recuperatorie-La-Hemiplegici-1
Definitie:Prin termenul de hemiplegie se desemneaza o perturbare tonico-motorie
consecutive unei leziuni unilaterale a caii piramidale la nivelul neuronuluimotor central,
antrenand tulburari controlaterale cand leziunea cauzata estesituata deasupra decusatiei
bulbare i ipsilaterala cand leziunea este suba c e s t n i v e l . A c e a s t a d e f i n i i e
s e r e m a r c a p r i n f a p t u l c a a d u c e i n p r i m plana ctivitatea motorie
ca ansamblu, indivizibila, responsabila de executareamiscarilor, mentinerea posturii si
atitudinii corpului.Debutul hemiplegiei:
Debutul hemiplegiei este de obicei brusc, cu sau fara stare
decoma. Cu cat leziunea cerebrala este mai ntinsa i atacul a
f o s t m a i b r u t a l , c u a t a t m a i p u t e r n i c a s i m a i n t i n s a este paralizia.
In prima faza se instaleaza flascitatea, manifestata prin lipsatotala a tonusului muscular
si a miscarilor active.PACIENT:
Nume: R.CVarsta: 75Sex: MOcupatie: -pensionar(fost director )Prezinta:a f e c t i u n e d o b a d i t a u n u r m a u n u i AVC ; - h i p e r t e n s i u n e ; -
a t e r o c l e r o z a ; -incapacitate functionala;-prezinta o
paralizie flasca.
Obiective:Pentru stadiul acut:prevenirea apariiei tulburrilor trofice cutanate, escarele de decubit

mentinerea mobilitatii si supletii articulare in amplitudini complete;
prevenirea instalrii retractiilor musculo-tendinoase i a contracturilor muscular
Pentru stadiul post-acut:-reeducarea hipotensiunii de ortostatism;- v e r t i c a l i z a r e a ;
reeducarea pozitiei sezind la marginea patului si t r a n s f e r u l i n
fotoliul rulant.
Recuperarea in stadiul acut:
1.Masajul (8membru inferior+8membru superior):Se aplica pe suprafetele predispuse
aparitiei escarelor de decubit.
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)
ELENA CRISTEA Exercitii de Gimnastica Recuperatorie La Hemiplegici
.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:
Ulexia apropierea unui segment de segmentul cu c a r e e s t e

articu'at (flexia anteraului pe ra+.

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+.
Pronaia rotarea spre degetul mare (palman 5os+
0upinaia rotarea spre degetul mic (palma n sus+.
8ducia ducerea memrului lateral (depr tare de

corp+. 8dducia aducerea memrului lng corp.
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
Na exerciiile pentru mem rul superior ne aezm

d e partea afectat.
Pentru simplificare precizez c exerciiile se aplica unui pacient cu o leziunie,
de partea stnga ce are. afectat deci partea dreapt. Na cei cu partea stnga
afec&tat se efectueaz acelai lucru de partea opus.
7.3.1.1. Exerciii din po&iia cucat pe spate
@ac mna pacientului este cu pumnul strns i dege&tele contractate
executnd exerciiile l i 2 se oine re&laxarea minii.4xerciiul l.ntindei raul
pacientului pe lng corp cu pumnul n 5os. /na stnga o aezai pe ncheietura
pumnului iar cu mna dreapt efectuai hiperextensia fiecrui deget n parte
ncepnd cu degetul mic (fig.ll+. @up ce, n acest fel ai reuit s desfacei pumnul
i deci acum pacientul are palma n 5os continuai s repetai de cte!a ori acest
exerciiu pn ce degetele snt relaxate complet
4xerciiul 2/na sting cuprinde anteraul deasupra articulaiei pumnului.

$ntercalai degetele d!s. ntre degetele pacien&tului i printr&o micare de extensie
i alunecare tragei mina (fig.12+.
=i. 2. ?
4xerciiul 2.
4xerciiul 3Poziia de plecare anteraul ndoit din cot la " grade pe !
ertical. /na dreapt ine ntinse cele patru degete de la mna dreapt a pacientului
iar cu mna stng moilizai degetul mare astfel 9Ulexia degetului
mare4xtensia/icri circulare n amele sensuri (fig.13+.
4xerciiul #Poziia de plecare anteraul ndoit din cot la " de grade pe !
ertical. /na stng cuprinde ante& raul deasupra articulaiei pumnului. /na drept
cu& prinde din interior degetele pacientului (fig. 1#+. Ulexia minii p5: antera
4xtensia minii pe antera /icri circulare din articulaia pumnului
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"
Indicaii dup cte!a repetri solicitm pacientului s execute micarea.

@ac nu rspunde solicitrilor noas&tre aplicm uoare tapotari la captul cellalt
al antera&ului pe suprafaa anterioar (muchiul rahio&radial+.4xerciiul )Poziia
de plecare anteraul flexat din cot n poziie !ertical, mma sting cuprinde
anteraul, mna dreapt cu degetul mare n palma pacientului celelalte # deghte pe
dosul palmei. Ulexai mna pacientului pe an&tera i solicitai acestuia extensia
degetelor (fig. 1)+.
=i. <M.
4xerciiul ).
$ndicaii9 8cest exerciiu se !a repeta la nceput numai de 23 ori deoarece
muchii ce snt solicitai snt mici i oosesc foarte repede.4xerciiul 6Poziia de
plecare degetul mare pe dosul palmei pacientului, celelalte # degere n 'palma

pacientului (fig. 16+.3"
Pronaa (rotarea spre interior a minii+ 0upinaia (rotarea spre
exterior a manii+4 x e r c i i u l P o z i i a d e p l e c a r e p r i z a
Aaat pentru mnadreapt (fig. 1+. /na
d r e a p t a i n e t o t e r a p e u t u l u i prinde mna olna!
ului astfel 9 degetele $$$, $S, S a>e pacientului snt prinse ntr degetul mare i ar
afrorulminii in<Itoterapeutu'ui. /i5lociul i inelarul inetotera
& peutului se gsesc ntre arttorul i degetul mare al pacientului, n timp ce dege
tul mic al inetoterapeutuluic u p r i n d e d e g e t u l m a r e a l p a c i e n t u l u i .
Fig.
E
OPriza minii dup Aaat.
4xerciiul
/na sting cuprinde raul deasupra cotului Ulexia anteraului pe r
a 4xtensia ante'rau'ui (fig. 1-+$ndicaii n timpul acestui e xerciiu
raul pacientu& l u i t r e u i e s f i e l i p i t d e c o r p . 0 e ! a i n s i s t a
ca flexia sse nealizeze pn cnd mna atinge umrul.
@up ce seexecut n mod pasi! de cte!a ori, cerei
p a c i e n t u l u i s #1
(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
4xtensia pe !ertical cu ridicarea raului nunghi drept cu

trunchiul.
;o' orrea raului concomitent cu

f i e x i a a n t e r a ului. 4xtensia anteraului pe ling corp.
(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.
Ulexia anteraului deasupra capului urmat

de pronaie i flexia minii cu extensia degetelor.
45

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
mare l aezai p*e dosul palmei. /na stng

c u & prinde anteraul deasupra cotului (fig. 21+.
4(
. 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+.$ndicaii 9 n timpul
aduciei i adduciei, cotul tre& uie s fie ntins. ;nd
executai flexia, mna pacientului treuie s ating
umrul. @up Ze exerciiul l poate realiza pacientul n
mod acti! !ei opune rezisten micrilor ae&znd mna
cu palma n sens opus direciei de deplasare a
segmentului pacientului.4 xerciiul 11Poziia de plecare
mna dreapt cuprinde din ex&terior mna pacientului,
degetul mare fiind pe dosul palmei, cealalt mna
cuprinde raul deasupra cotului pe partea interioar
(fig. 22+
7.3.1.. Exerciii pe care pacientu poate s e execute sin$ur cu a,utoru !

e!'ruui sntos
/ulte din exerciiile pe care le&ai fcut cu a5utorul altcui!a le putei repeta
singur, contriuind astfel n mare msur la scurtarea timpului pentru recuperarea
d!.Pentru nceput s&ar putea s !i se par o acti!itate ane!oioas, plictisitoare, dar
asta !a fi numai la nceput. 4ste posiil ca primele ncercri s nu constituie i o
reuit, dar, categoric, acesta nu !a fi un moti! de descura& 5are i de renunare ci
dimpotri!, innd cont c Orepe&tiia este mama n!turii cu atenia
concentrat, cu fora moilizat, mai ncercai o dat i nc o dat pn cnd,
micarea propus o !ei realiza cu uurin. @orina de a progresa, la care se !or
altura rezultatele pe care le !ei nregistra !or constitui stimul permanent n aceast
acti!itate nu lipsita de satisfacii. Na exerciiile pe care noi !i le&am propus putei s
mai adugai i altele, pentru c e ine s tii, o parte din acestea ne&au fost
sugerate chiar de pacieni ca d!., care, n dorina de a n!inge handicapul, munceau
foarte mult singuri a5ungnd s descopere exerciii care s&i a5ute s realizeze ct
mai repede micri corecte i acti!iti necesare, ncercai de la nceput s trii ct
mai independent i mai ales nu uitai s ! a5utai de memrul afectat n tot ce a!ei
de fcut. 4ste ine s e!itai, i de ce nu, chiar s refuzai a5utorul celor ce !
ncon5oar, pentru realizarea unor ser!icii pe care le putei face i singuri. Joate
acestea ! !or a5uta s ! meninei autonomia i !iaa d!. s se desfoare aproape la
fel ca nainte. Soina, perse!erena i contiinciozitatea constituie factori de az de
care de& pinde n mare parte renceperea !ieii normale n mi5lo&cul familiei,
prietenilor i chiar n mijlocul colegilor de serviciu,)
p.51
4)eriii !in poliia, ulat pe spate

4xerciiul 13.P o z i i a d e p l e c a r e m n a s n t o a s
c u p r i n d e c e l e # degete ale minii paralizate, degetul mare pe
d o s u l p a > & m e i ( f i g . 2 # S Ulexia minii4 x t e n s i a m i n i i i
a degetelor
=i. 2K ?
4xerciiul 13 (1 2+.
4xerciiul 1#.P 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 a l
minii paralizateeste cuprins de primele 3 degete (fig.
2 ) + . ;ircumducii ale degetului mare n amele sensuri.4xerciiul 1).P 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 m i n i i memrului paralizat
(fig. 26+.
)2
=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
amelor mini palmele orntate n 5os (fig. 2-+.
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
-.3. 4Exerciii pentru recuperarea memrului inferior @eoarece i segmentele

ce alctuiesc memrul inferior acioneaz dependent unul de cellalt este suficient
o afeciune la unul din muchii urui segment pentru a determina modificri n ceea
ce pri!ete una funci&onalitate a ntregului memru.$n cazul hemiplegiilor, la
rmomrul inferior snt afectai mai mult muchii fiexori i n mod deoseit este
afectat piciorul. @atorit acestor considerente, n deplasarea lor, hemip'egicii ridica
oldul i&[ proiecteaz nainte putnd astfel s realizeze pasul cu memrul paralizat
eliminnd flexia genunchiului. Fligaia celor ce se ocup de recupe&rarea unui
hemiplegie este de a insista pe rea'izarea fle&xiei genunchiului i eliminarea

micrii de ridicare a azinului nc de la primii pai pentru a nu lsa s se
instaleze oinuina asupra creia !a fi mai greu s se
' L inter! in. Pentru efectuarea exerciiilor cu memrul in&
R
f e r i o r
!
a e z a i
p e
p a r t e a
a f e c t a t .
: '
9
-.3.1.
4)eriii pasive'"
4xerciiul 2" 9P o z i i a d e p l e c a r e o m n c u p r i n d e
p i c i o r u l d i n lateral ntre degetul mare i celelalte patru degete,
cealalt m n a p u c d e s u s d e g e t e l e p i c i o r u l u i ( f i g .
# 3 + 9 ndoii degetele piciorului spre talpa piciorului ntindei degetele picio
rului
Uig.
KC ?
4xerciiul 2" (12+.
4xerciiul 3.P o z i i a d e p l e c a r e & o m n c u p r i n d e g a m a
d e a s u p r a articulaiei piciorului, cealalt mn o a ezai pe talpa
spre partea extern (fig. ##+.
2
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/.
(fig. #)
Fig. 44
x Exerciiu 3/.
(fig. #)
hiului3
=i. KD ?
4xerciiul 32 (l 2,X
ridicai piciorul spre !ertical aezai piciorul pe pat.
=i. KE
4xerciiul 33.
aezai piciorul pe pat.

=i. KE
4xerciiul 33.
=i. KD ?
4xerciiul 32 (l 2,X
ridicai piciorul spre !ertical
cealalt pe suprafaa superioar a pi&cioru'ui (fig. #+. aplecarea

genunchiului spre exterior re!enire$ndicaii 9 mn de pe picior treuie s apese
pe suprafaa acestuia astfel ca partea intern a piciorului s nu prseasc
patul.4xerciiul 3#.Poziia de plecare o mn cuprinde gama su glezn, cealalt
mn apuc genunchiul din lateral (fig. #-+. ducei memrul inferior spre lateral
ducei memrul inferior n sens in!ers aezndu&1 pe cellalt memru
=i. MH
0timularea flexiei dorsale a plantei.
=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
p a r a m e t r i s u p e r i o r i . ;omplexele de exerciii oferite cuprind o

minare dem i c r i a n a l i t i c e i g l o a l e n ! e d e r e a o i n e r i i
rec u p e & rrii funcionale i deci a formrii deprinderilor
m o t r i c e . F micare coordonat, precis, corect se poate
realiza n u m a i p r i n a c i u n e a s i n c r o n i z a t a m u c h i l o r
a g o n i t i i antagonist, prin participarea
c o n t i e n t i a c t i ! a olna!ului i pe aza multiplelor
repetri.@ e a l t f e l i a n t r e n a m e n t e l e s p o r t i ! e d e
p e r f o r m a n ce urmresc formarea i perfecionarea
deprinderilor mo&t r i c e s e a z e a z p e m i n a rea m e t o d e i
lucrului analitic
-1
=ix.
)D , 4'erciiul 3- (1,2+.
-.3.2.
4)eriii ative
@up cte!a repetri ncercai toate aceste micri separat cu fiecare picior,
deci, fr a5utor. Qu dup rnult timp le !ei putea executa n mod cursi! i apoi chiar
cu rezisten din partea unei alte persoane sau aplicnd n 5urul gleznei manoane
umplute cu nisip. ;u timpul !ei putea exersa la icicleta ergometric sau !ei face
exerciii cu gheata ortopedic i cordon elastic de cauciuc. 0e recomand ca toate
exerciiile, att pentru memrul supe&rior ct i pentru cel inferior s fie nsoite de
exerciii de respiraie, deoarece se tie c un creier ine oxigenat funcioneaz la
parametri superiori.;omplexele de exerciii oferite cuprind o minare de micri
analitice i gloale n !ederea oinerii recupe&rrii funcionale i deci a formrii
deprinderilor motrice.F micare coordonat, precis, corect se poate realiza numai
prin aciunea sincronizat a muchilor agoniti i antagonist, prin participarea
contient i acti! a olna!ului i pe aza multiplelor repetri.@ealtfel i
antrenamentele sporti!e de performan ce urmresc formarea i perfecionarea
deprinderilor mo&trice se azeaz pe mbinarea metodei lucrului analitic
p.81
cu metoda gloal, deoarece numai aa se poate oine randament maxim.
2. Redo'"ndirea autono!iei
@ac n primele zile depindeni n totalitate de cei ce ! ncon5oar, treptat
putei s realizai unele aciuni fr a5utor din afar i asta chiar n perioada n care
nu putei nc prsi patul, cum ar fi 9 schimarea poziiei corpului prin ntoarcere

n pat pe partea olna! i pe cea sntoas, aezarea la marginea patului, culcarea n
pat, ridicarea n picioare i aezarea pe pat sau pe scaun.;nd medicul hotrte c
putei prsi patul, !ei n&!a s mergei, s urcai i s coori scrile, s !
mrcai i s ! dezrcai precum i s ! splai. ;um s realizai toate acestea ct
mai repede i ct mai uor !ei afla din paginile ce urmeaz.
2.1. "ntoarcerea "n pat pe partea parai&at
@eoarece n realizarea unei micri n care este angre&nat tot corpul, capul
are rol conductor i n acest caz prima micare !a fi de ntoarcerea capului spre
partea olna!a. ;u mna sntoas apucai marginea saltelei n dreptul oldului de
partea paralizat. Piciorul sntos este ndoit din genunchi cu talpa pe saltea. Pentru
a realiza n&toarcerea ! ridicai uor ezutul i ! rsucii printr&o micare de
mpingere n piciorul sntos, umrul para&lizat i capul.
p.82
".2. ntoarcerea n pat pe partea sntoas@in poziia culcat pe spate ntoarcei
capul pe partea sntoas. ;u m'na sntoas tragei raul paralizat spre partea
sntoas pn ce umrul prsete contactul cu patul. Piciorul sntos cu
genunchiul ndoit este su ge&nunchiul piciorului paralizat, ntoarcerea se
efectueaz prin mpingerea n clciul piciorului sntos (!rful pi&ciorului trage
genunchiul memrului paralizat+, n umr i cap prin ridicarea ezutului i
mpingerea acestuia uor spre spate.".3. 8ezarea la marginea patuluiPentru a ! fi
mai uor !enii ct mai aproape de mar&ginea patului, de partea sntoas. Piciorul
sntos su piciorul olna! amele cooar la marginea patului cu genunchii
ndoii. Prin mpingerea n antera i apoi n mn ridicai trunchiul. @ac aa !
este greu .apucai mar&ginea saltelei.".#. ;ulcarea n pat;u spri5inul pe marginea
patului ducei picioarele sus a5utndu&! de piciorul sntos la ridicarea piciorului
olna!. Bor ! lsai greutatea de pe mn pe antera dup care ! ntindei la
orizontal. @ac capul este mai 5os, adic nu este pe pern, ndoii piciorul sntos
i prin apsare pe ta'pa dega5ai ezutul i mpingei n sus corpul.p.83
".).
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,-#

Caiet Practica NEURO USH Sidenco Recuperare in Hemiplegie Hemiplegici

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Caiet Practica NEURO USH Sidenco Recuperare in Hemiplegie Hemiplegici

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Recuperare in hemiplegie hemiplegici

Objective To compare home-based cardiac rehabilitation (CR) with usual care

Home-based cardiac rehabilitation is an attractive alternative to no

Received 12 November 2012

Revised 12 November 2012

Accepted 22 November 2012

Published 18 December 2012

To compare home-based cardiac rehabilitation with usual care in elderly

Home-based cardiac rehabilitation improved exercise capacity among

This population of elderly patient had a high level of comorbidity and

Strengths and limitations of the study

The randomised design provides a higher level of evidence.

This population represents the real-world scenario of elderly cardiac

The size of the study did not allow subgroup analysis.

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alternative encouraged to participate in the centre-based CR programme (outside

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they both found a sustained improvement in exercise capacity after 12months, if

with mean 6MWT=308.4m120. In healthy elderly subjects, mean 6MWT is found

Contributors BO designed and initiated the study, collected the data,

Funding This work was supported by VELUX FOUNDATION.

Competing interests None.

Patient consent Obtained.

Provenance and peer review Not commissioned, externally peer

Data sharing statement No additional data are available.

. Exercise-based rehabilitation for patients with coronary heart disease:

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. Getting the most out of cardiac rehabilitation: a review of referral and

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and other societies on cardiovascular disease prevention in clinical practice

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[Abstract/FREE Full text]

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5.2. Exerciii pentru reeducarea mersului

uoar pronaie i degetele flexate. Membrul inferior paralizat este

Exerciii premergtoare mersului

ridicarea alternati! pe !rful unui picior (fig. )

alansarea unui picior nainte i napoi (fig. )"+.4xerciiul #). alansri

Indicaii 9 tendina este ca flexia genunchiului s se execute concomitent cu

micarea exagerat, dar la nceput pentru a putea fi simit i neleas treuie

2. hemiplegii datorate compresiunii cerebrale

Recuperarea va ncepe cu o posturare a pacientului n pat pentru evitarea

Scopul acestui nivel va fi de a invata bolnavul catre auto deservire.

Alternarea periodica a pozitiei membrelor in pozitia bolnavului pe spate si pe

Pentru a diminua hipertonusul muscular si preintimpinarea aparitiei

O importanta mare se acorda miscarilor izolate in articulatii. Petru aceasta

Masajul, in lipsa contraindicatiilor, se incepe: