help me to t/t a hemipelegia case

[sharmaphysio]

hi physios
m treating a hemi case of left side.he has gained enough power.but cant use it to full extent in works.he is right handed so he normally has less work with left,so what should i say him to do?
also he has restricted external rotation of shoulder,and cant't supinate with elbow extended but can do so with elbow flexed.m giving streching of rotaters as m externally rotating his shoulder.is m doing right?:eek

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[thirunelveli]

hi,
you can suggest him to do simple motor activities for hand so as, make him encourage to do daily activities such as locking , unlocking towel wringing, handling utensils. you can try weight beariing to supinator movement by making your client in sitting and facing a table with outstrecthed hands(bilateral) and do supination movement with the normal and affected hand interlocked

[sharmaphysio]

thanks alot for your reply.i will try it

[jowales]

How does your patient walk ? can he maintain his midline during walking. The arm function is inflenced by the way patient weightbears and walk. Majority of the time that is the problem especially when they have some power but not able to use it.

[sharmaphysio]

when he walks his right side pelvis drops ie opp sides

[sharmaphysio]

he has atem diff in normal n effected side too,till now he is not using his full power gained in daily living,what should i do?

[kparanipt]

Muscle power assessment won't help to rehabilitate the stroke patient. As per Ur questions, u r talking about muscles of lower limb.

You have to do following things.

>> Assess his gait in all three planes
>> Find out the missing components of it, for this you must know the normal components of gait
>> Practice the missing components
>> Practice with the activity
>> Give numerous opportunities to practice it.

U can find all these things in MOTOR RELARNING PROGRAM; this will be best program for stroke clients.
If u combines with bobath, I assure that u will get better results.

IN STROKE CONDITION, U SHOULD NOT STRENGTHEN THE MUSCLES BUT U SHOULD GET THE CONTROL OF MUSCLES.

[sanagupta]

Hello!
I agree in stroke.. one should not strenghtn but get control...Going little off the main question..But what should be done if right hemi is complicated by prestroke frozen shoulder of 20 years..where u r not very sure of strengh and range before the stroke...patient has a verbal aphasia also(MCA territory)his gait is normal after 20 days physio but arm still laks so called strength....may be control....(i m not sure what to use...as he is coming to me after 20 days of physio from somewhere else)
Regards
Sana

[highmode]

nobody has yet stated that turning muscles off is often harder than switching them on. Look for muscle overuse on strong and weak sides and through the trunk. If a patient is rigid because of fear of falling, no confidence in the weak side, or inability to switch off a muscle (may still be in pattern) then you will never get normal gait til you retrain this overuse. I find sitting the patient on a high/low mat and raising them up so their feet can swing then asking them to gently swing their legs is a good activity which shows them how rigid they are and perhaps allows them to experience some relaxed movement. This can be progressed to relaxed standing by asking for some gentle knee bending and encouraging estending without locking out the knees. You can also try heel toe touching or if this is too advanced just the knee break prior to swing. You really need to do a good gait assessment to break the process out at the point they need to shape their effort.

highmode

[piyushmadani]

if u still treating same patient try with constrained movement therapy. in this we constrain use of unaffected hand that is supposed to increased use of affected hand for functional activities..

[sdkashif]

Stroke rehabilitation is a combined and coordinated use of medical, social, educational, and vocational measures for retraining a person to his/her maximal physical, psychological, social, and vocational potential, consistent with physiologic and environmental limitations.

Many studies show that stroke rehabilitation is effective and can improve functional ability, even in patients who are elderly or medically ill and who have severe neurologic and functional deficits. Experts in stroke rehabilitation abound, but none have proven anything about rehabilitation to the satisfaction of anyone else.

Evidence from clinical trials supports the premise that early initiation of therapy influences the outcome favorably. When the initiation of therapy is delayed, patients may develop secondary avoidable complications, such as contractures and deconditioning, in the interim.

The course of motor recovery reaches a plateau after an early phase of progressive improvement. Most recovery takes place in the first 3 months, and only minor additional measurable improvement occurs after 6 months following onset; however, recovery may continue over a longer period of time in some patients who have significant partial return of voluntary movement.


A number of treatment approaches are available and you may chose according to your needs and assessement of the patient. These are

A-Conventional Physiotherapy programme - Traditional therapy - Range of motion, strengthening, mobilization, and compensatory techniques. After initial assessment, a physical therapy program should begin with passive exercises, where the major joints of the paretic limb are moved through a full range of movement (ROM). As soon as patients are stable and can tolerate more active therapy, encourage them to sit up (initially in bed and later in a chair), to stand, and to transfer safely; then, they can commence ambulating with assistance and aids as required. The physical therapist can provide splints and braces to support joints and limbs, to treat and prevent complications (eg, shoulder-hand syndrome, spasticity), and to assist the patient in walking.

Early after stroke, patients often have flaccid paralysis that can potentiate further complications such as contractures, joint subluxation, and nerve pressure palsies. For instance, common upper extremity examples are shoulder subluxation, ulnar neuropathy, and elbow flexion contractures. Physical therapy should focus on appropriate positioning and avoidance of traction, which can harm joints previously stabilized by muscular tone. Range of motion (ROM) should be preserved during this phase. Later efforts can be pursed to reeducate weak musculature through modalities that provide sensory feedback.

Independent ambulation is an important ultimate goal, often requiring several stages of recovery. Initially, patients exhibit poor trunk control, are unable to bear weight on the affected extremity, and are unable to advance the leg during the swing phase. Initial therapy should focus upon posture, trunk control, and weight transfer to the hemiparetic leg. Many patients have weakness of ankle dorsiflexion and require an ankle-foot orthosis (AFO) to prevent foot drop and maintain knee extension during weight bearing.

When the patient is stable, assess his or her ability to perform activities of daily living (ADL), such as dressing and undressing, bathing, personal grooming, toileting, preparing meals, and eating. If the patient is returning home, an assessment of the residence identifies potential problems and necessary modifications (eg, handrails, moving a bed to a ground level room), thereby providing confidence to the patient and family.

Recreational therapy improves the functioning, independence, and self-confidence of patients following stroke through participation in individual and group recreational activities that they enjoyed before their strokes and through participation in new ones. The therapist must assess the patient's medical condition and physical capabilities, as well as the patient's interests and hobbies. Then, the therapist must help the patient set realistic goals and make any necessary modifications to achieve these goals. Recreational therapy not only allows the stroke patient to practice motor skills but also allows the patient to remain socially active. Recreational therapy includes leisure activities, such as going for a walk, fishing, and gardening, as well as involvement in family and community activities, such as playing cards and going to a restaurant.

See more on Achievement of Human Potential

B-PNF ( KABAT TECHNIQUES) Techniques- Proprioceptive Neuromuscular Facilitation Techniques - Knott, Voss - Proprioceptive neuromuscular facilitation

Stimulation of nerve/muscle/sensory receptors to evoke response through manual stimuli to increase ease of movement and promote function

Normal neuromuscular mechanism capable of wide range of motor activities within limits of anatomical structure, developmental level, and previously learned neuromuscular responses; integrated and efficient without awareness of individual muscle action, reflex activity, other reactions

Deficient neuromuscular mechanism inadequate to meet demands of life because of weakness, incoordination, adaptive joint shortening/immobility, muscle spasm, or spasticity

Specific demands placed by physical and occupational therapists have facilitating effects of neuromuscular mechanism and reverse limitations of patient

Mass-movement patterns keep with Beevor axiom (ie, the brain knows nothing of individual muscle action but only movement).

See Proprioceptive Neuromuscular Techniques (PNF)



C-Bobath - Neurodevelopmental training Muscle patterns, not isolated movements, used for movement

Inability to direct nervous impulses to muscle in different combinations used by persons with intact CNS

Suppress abnormal muscle patterns before normal patterns are introduced

Associated reactions - Mass synergies avoided, may strengthen weak unresponsive muscles (reinforces abnormally increased tone reflexes and spasticity)

Uses reflex-inhibiting patterns to inhibit abnormal postural reactions, but facilitates automatic voluntary movements

Abnormal patterns modified at proximal key points of control (eg, neck, spine, shoulder, pelvis

See more on Bobath Method

D-A motor relearning programme :

It is mainly practised in Australia and have been originated there. Success with accelerated recovery has been claimed by the practitioner doing practising this method. Although many comarative studies have been done but its long term success over other physiotherapy methods has yet to be established though out the world after its use by the other practising physiotherapist all over the world particularly in other countries other than Australia region.

E- Brunnstrom - Enhances specific synergies through use of cutaneous/proprioceptive stimuli; central facilitation using Twitchell's recovery

Stroke syndromes present with various alterations in motor, sensory, and cognitive function, each unique in clinical presentation and prognosis. Although there are general principles of stroke recovery, no two patients share the same experience. Understanding the correlated physiologic and anatomic changes in the brain helps identify which syndrome is present and how best to institute comprehensive rehabilitation to meet the individual needs of the patient.

[sdkashif]

The valuable references for Further reading are as follows:

Physical Therapy of the Shoulder. Second Edition By Robert A. Donatelli

Cash's Textbook of neurology for Physiotherapists. 4th Edition by Patricia A. Downie

Tidy's Physiotherapy. 13th Edition by Stuart Porter

Physical Rehabilitation. Assessment and Treatment. Third Edition. By Susan B. O'Sullivan & Thomas J. Schmitz

Clayton"s Electrotherapy. 10th Edition By Sheila Kitchen & Sarah Bazin

Clinical Electrotherapy. Second Edition by Nelson & Currier

Therapeutic Expercises. Foundation and techniques. Third Edition by Carolyn Kisner & Lynn Allen Colby

Carr JH, Shephard RB: A Motor Relearning Programme for Stroke. 2nd ed. Oxford: Butterworth-Heinemann; 1992

Morris DM: Constraint-Induced Movement Therapy for Motor Recovery After Stroke. NeuroRehabil 1997

Proprioceptive Neuromuscular Facilitation Techniques - Knott, Voss - PNF. Third Edition

Brunnstrom,S: Movement therapy in hemiplegia. Harper & Row, New York.

Bobath, B: Adult Hemiplegia: Evaluation and treatment. 2nd Edition

Calliet, R: The Shoulde in Hemiplegia. FA Davis, Philadelphia.

Davis P: Steps to follow- A guide to the treatment of adult hemiplegia, Springer-Verlag, New York. 1985

Duncon, P and Badke, M: Stroke rehabilitation: The recovery of motor Control. Year Book Medical publication, Chicago, 1987.

Charness, A: Stroke/Head Injury- A Guide to Functional out come in Physical Therapy Management.