Newly Qualified - Please Help!

[Lil_Physio]

Hello,

I'm new to this site so be gentle! I have just qualified as a physio and am working on my first rotation. I have limited stroke physiotherapy experience and would appreciate any advice anyone could give....

I have a 65 yr old patient whos just been referred to myself. He suffered a right cva 6 months ago. Although he has made leaps and bounds progress wise, his lower limb selective activity remains reduced.

He is able to reach plantargrade at the ankle. Gait - He has reduced hip and knee flexion and circumducts the hip. He is able to laterally weight transfer onto hemi side well, and performs mini squats well, but has reduced hip flexion during gait and compensates by circumducting or hitching the hip.

Could anyone give me any tips on how to re-educate a normal gait pattern, and stimulate hip flexion please? ? facilitation best handling, ? stepping practice ? ..treatment to normalise movement

I know this is probably an easy Q to ll you intelligent experienced physios but I would be so grateful for your advice. I am really keen to learn.

Thank you in advance,

Lil_Physio x

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[Gawaine]

strokes are tricky things to fix... to be good at it it takes years and a lot of continuing education and mentoring...
but to help you along, try this basic plan:

1) ask for a motion (for example, "lift your leg" or "walk over here")
2) if they can't do the motion, facilitate it with the lightest/least-intrusive facilitation: a) verbal commands, b) hand over the part you want moving without any real pressure, c) hand over the part you want with very light pressure increasing to moderate pressure
3) if they can't do the physiologic motion that is necessary with your facilitation, try passively taking them through this range
4) if they don't have the range, you need to stretch the muscles that are spastic/limiting the range


as far as what you're describing, there are lots of things that could be causing these deviations... you essentially need to put your hands on the patient when they ambulate and fix whatever is going wrong...
lower extremity circumduction and hip hike are often due to lack of active dorsiflexion... they may benefit from an AFO and dorsiflexor strength training (AFOs should almost always be articulating-- never solid)... they also may be keeping their knee stiff from terminal stance through heel strike--- try pushing directly inferiorly through the iliac crest when the extremity is in terminal stance so that the knee achieves some flexion and the extremity can be swung through without circumduction... mirrors also may help at this point... also consider that most of the swing phase of gait comes about as a function of the trailing limb during terminal stance being in hip EXTENSION and the extensors release, allowing gravity and momentum to swing the leg through to midstance, where the quads pull the knee into extension for terminal swing and into heel strike... strength of your hip flexors is not really a factor in normal gait, though spasticity and decreased passive range into hip extension is HUGELY important...

i suggest you start your education with Pat Davies' "Steps to Follow"... it's one of the quintessential books on stroke rehab... as my karate instructor used to say "when you achieve black belt, you education has only just BEGUN"... graduating and getting your license is just the beginning!!!

keep us posted!!


patrick, MPT

[Judith Mollet]

I agree with Gawaine on the whole including the bit about education and the black belt. I would advise on the reading matter the book by Bente E Bassoe Gjelsvik "Form and Function" The new edition should be out now. Pat Davies was one of the leading Bobath teachers but the original edition of "Steps to follow" was 1985. I even recognise the paients in the pictures from my time working in Bad Ragaz. Neuro-physiological and -anatomical knowledge and the Bobath concept have made enormous changes in the last years, particularly as we consider neuroplasticity and it's consequences. One thing that is not really on now (is in the older Steps to follow)is the lifting two arms together self mobilising stuff which, with the wrong scapula setting and movement likely to cause problems. If you really want to get ahead in Bobath the whole IBITA basic course starts you off. Then there are the advanced courses that are never ending but always brilliant as just watching the instructors treat is often amazing and inspiring. I did a week advanced with UK based Mary Lynch last year and it was "only" "understanding the role of "head, neck, thorax and scapula" in postural control and functional reach". Superb! All this stuff with trunk and scapula and they walked better! And the good thing is, you can do all the neuro stuff often with your orthopädic patients and geriatrics as the principles still apply. Wish you a good start in your (neuro-)physio career