CVA with hip hyperextension

[jennaPT]

I have a client who is s/p cerebellar CVA. He is ambulatory, but continues to have losses of balance (especially when distracted or with head turns) that result in rapid hip hyperextension (like a reverse jackknife). This happens with gait and static stance. He is able to maintain upright posture when reacting to pushes or peturbations, but doesn't seem to have the automatic postural control with standing and walking. Any treatment ideas? Thanks!

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[bensynergy]

recently i also working out with a cerebellar cva patient. she has poor postural control in standing n gait, s well s dynamic sitt (i let her sit on a discopad-balancing pad, she has diff in controling upright posture + movement). s we know, cerebellar controls trunk proprioception/posture and balance, s well s skilled movement. to inhibit hip hyperextend, should try weight bearing on knees (proximal joints weight bearing) in kneeling position for hip n trunk control n balance first. then proceed to standing balance (balance of trunk, hip, knee, ankle). he able to maintain trunk in upright posture during pushings and perturbations may due to stiffening of trunk muscles.
pls correct me for any misleading info.. thanks

[Dr Damien]

Hey, how are you guys? Interesting what the discussion is about. Although the description of the assessment is not complete but you mentioned that rapid head turns causes abnormal gait and loss of balance. my guess is that your client has issues with coordination and disturbances in vestibular function.

i would reassess him for vestibular function and consider vestibular rehabilitation. the good thing is you know provocative factors to this abnormal loss of balance, this is where I would focus my treatment to encourage habituation.

exercises such as standing ...one hand or both on a table then gradually turning head left to right...increasing speed as the client is able to maintain his balance, then progressing to one hand or no hands...regulating speed of head turns as able

i would consider...walking parallel to a wall in a straight line, progressing to walking and turning head left and right

i would consider also, exercises done with eyes closed

but i would assess vestibular function first, looking out for signs of nystagmus and vertigo...

i would add coordination exercises...walking in a straight line, waking in a straight line and moving arms etc

[irishneurohead]

vestibular rehabiliation is the way to go - looking for nystagmus is unfortunately not really going to be of benefit because the patient will have nystagmus - a central nystagmus due to the central lesion. You could do a full oculomotor assessment to assess for a peripheral problem also but it should just be a central problem.

Unfortunately the cerebellum/central vestibular issues do not respond well to physiotherapy - so you need to ensure safety, lots of education, and teach the patient how to use other available strategies (somatosensation and visual).

I would also work on lots of core stability to help facilitate better anticipatory postural adjustments and also looking at dissociation of the head on trunk.

Hope it all goes ok.

[junior_physiotherapist]

Yes, I do agree with somatosensory training,weight bearing ex's.............

[Dr Damien]

The input on this topic is much appreciated...and my reply is either gonna be taken with loathe or with much appreciation...


Retraining somatosensory strategies, core stability, postural control, weight bearing still fall under the huge umbrella of vestibular rehabilitation becausing maintaining equilibrium requires control from this system. I would be careful in assuming that because a patient has been diagnosed with a stroke, that means I should find central issues generally. I say this because I have seen patients who generally have been diagnosed with a stroke and have no central nystagmus, likewise elderly clients with an all clear for neurological problems present with seemingly central vestibular disturbances.

I would still do a full oculomotor examination because it will help design the exercises that this patient can practice. Once a vestibular issue is suspected, its good to try and stimulate much of its response as you can.

I do not agree that central vestibular issues do not respond to physiotherapy, I would agree if one said this takes time. And our current knowledge on neuroplasticity suggests thus,In some patients habituation will never occur, other aspects of your overall vestibular rehabilitation will help accomodate for this...i.e your somatosensory strategies etc...as i have said you cannot use these strategies effectively without stimulating some aspects of your vestibular system...

I give an example...A young lady I saw once about two years ago had suffered a brain stem stroke due to a verterbral artery clot. spent a few weeks in the hospital, Initially could not maintain her balance, unable to acquire equilibrium, but the inpatient physiotherapist included several aspects of an overall vestibular stimulation to this womans therapy... It took a while but after several weeks in the hospital and followup by the community therapist...she started walking about unaided...

My point is, we deal with patients individually, what we find is what we aim to correct...assumming all patients are similar is the first error to managing anyone...

Vestibular rehabilitation is very wide...

Does our patient present with an ataxia? what type is it? again...assumming that your patient should present with what the diagnosis suggests is not ideal...

Had a woman referred to me once by a doctor who diagnosed "hemisensory deficits secondary to a previous stroke" in a lady who presented with left side heaviness...

on assessment...your guess is as good as mine, there was no sensory issue...what she had was a mechanical problem in her trunk that was more musculoskeletal...(this woman was mobile, her balance was 53/56 on the Berg scale, no issues with tone, no vestibular issues,nothing to suggest a neuro problem)
She had side aches when she walked too long, this was relieved partially by heat and stretching...suggesting a mechanical problem from imbalance issues in her trunk probably from her previous episode of " stroke" as the doctors put it...

Educating your client is good, but we should not kid ourselves, often enough these patients, if they have had their issues for long, generally have their own coping strategies that work well for them...so even without your input these patients will move in the safest possible ways for themselves for as long as they have no cognitive impairments...

With practice, they often get good at performing a function anyway...and this is without your input...

Retraining, head and trunk dissociation is a fantastic idea...again, you cannot do this without stimulating some aspects of your vestibular system...remember that the problem with our client is inability to maintain equilibrium when he move his head or walks...

Corestability...again another brilliant aspect of maintaining equilibrium...again having a strong core does not automatically translate into good postural control...good postural control when changing postural sets is the issue with this client not his core stability....otherwise why would he ba able to stand...or sit and maintain balance in static situations... this suggests his ability to recruit the right intergeration of muscles for postural control during changing sets is the issue...again another aspect of vestibular influence...

Weight bearing....another good idea...but how functional is kneeling...or prone kneeling weight bearing exercises? how much time do we spend on our knees to require this function? how many of our elderly patients will be able to do this...considering most of them have hip/knee issues...If my patient is able to maintain blance in standing, why do i need to take him/her milestones back? i would focus my balance therapy in standing...I may want to include ability to maintain balance during changing postural sets, ie...kneeling to standing, sitting to standing, lying to sitting...all these are more functional than static weight bearing training...

What should be important is, what is the problem with this patient? once that rings in our minds, then we can start to solve that problem...

We just have to manage our patients individually and not follow generic textbook advise...

Lets manage what we see based on what we know now....

cheers

[irishneurohead]

Loathe.

I have a couple of issues with certain points raised:

1) i think there is an definite difference between vestibular rehabilitation and balance rehabilitation. Balance rehab being the wider context of all the varying contributors to postural control.

2) Obviously all patients who have a stroke wont have a central nystagmus - but the topic in question was specifically about cerebellar stroke.

3) Elderly people with normal neuro and seemingly central issues: depends on what aspect of the oculomotor assessment and the contribution of age related changes e.g. saccadic eye movements

4) "I do not agree that central vestibular issues do not respond to physiotherapy, I would agree if one said this takes time. And our current knowledge on neuroplasticity suggests thus,In some patients habituation will never occur, other aspects of your overall vestibular rehabilitation will help accomodate for this...i.e your somatosensory strategies etc...as i have said you cannot use these strategies effectively without stimulating some aspects of your vestibular system..." - in terms of habituation with vestibular rehab its more to do with dizziness and its broad spectrum of symptoms.

5) "My point is, we deal with patients individually, what we find is what we aim to correct...assumming all patients are similar is the first error to managing anyone..." - how patrionizing is this?

6) "What should be important is, what is the problem with this patient? once that rings in our minds, then we can start to solve that problem...

We just have to manage our patients individually and not follow generic textbook advise...

Lets manage what we see based on what we know now...." - again very patronizing.

7) I still stand by the assertion that these cerebellar ataxias dont improve from specific vestibular rehabiliation. Depending on other issues they may improve with balance rehabilitation and training of other sensory strategies.