Quadriceps activation!!!!!1

[Judith Mollet]

Ahem.... this is a stroke patient. Can he sit properly? What is his trunk control in sitting like? what can the upper limb do? has he had any physio previously or nothing for two years? This is probably not just quadriceps, standing needs more than quads and it will need a neurological physio approach and not only an orthopaedic approach with SLR. Has he Symptoms of sensory deficit/neglect /perception problems.? More information please to help you more.

[Gawaine]

how much activity in the plantarflexors? i can't imagine a hemiplegic with plantarflexors activating and NOT the quads... there's gotta be SOME quads... if you can get the patient in to standing with assistance, increasing the proprioceptive input through the knee might increase activation of the quads...

if you can paint us a better picture of what that lower extremity looks like (as well as the non-affected LE) i might be able to offer more specific ideas...

[fire_ice]

ok!!!!!let me describe him in detail, physiotherapy taken previously only for 1 month at the time when he got stroke since then no physio!!!!! was instead taking taditional chinese medicine and accupuncture......
left side stroke:- UE Non functional with severe contractures
LE no hip control,no quads,Plantar flexors
grade 2
Right side Non affected side both upper and
lower extremity grade 5 has been doing
SIT TO STAND at home on the strong side
and pulling up with the strong upper extremity.
Treatment tried:- Standing using Knee immobilizer with
some support of the trunk,Quad
activation through static quad asking
the patient to move the patella
Electric stimulation,NDT tech........
..for hip control and trunk balance .
WHAT else can i try???????

[Canuck Physio]

Thank you for the details, however still appears difficult to sift out the information.

In that case we have a very low functioning individual.

[fire_ice]

ya he is completely dependent in his functional activities,i m am still trying on Activating Quads and working on his TA,and using kneeling position to gain some hip control, Bridging standing with knee immobilizer but still needs some amount of trunk support....to maintain the erect posture.

[Judith Mollet]

"ok!!!!!let me describe him in detail, physiotherapy taken previously only for 1 month at the time when he got stroke since then no physio!!!!! was instead taking taditional chinese medicine and accupuncture......
left side stroke:- UE Non functional with severe contractures
LE no hip control,no quads,Plantar flexors
grade 2
Right side Non affected side both upper and....."

OK, let us get something sorted out. This patient has not got an unaffected side!!!
The left side in this patient, even if it had better muscle control than you have described would possibly not function well as this is often seen in left sided (rightside brain) hemiplegia.Using the BETTER side to pull up by force for ages tends to reinforce disuse and wrong movement patterns on the affected side and also produces increased tone on the BETTER side. Have you tried to do anything with the UE left side or have you left it? This person must have massive changes in the body picture represented in the brain, possibly severe neglect. Patients with neglect do not know what is wrong with the affected side as they don't really know it's there! In neuro courses we constantly hear the phrase "if you don't use it you lose it". How is the tone in trunk/UE/LE increased/decreased ? Does this person sit straight or slanted to one side ? Are there structural changes in the trunk as well as UE?
I think you have to go back to looking and improving trunk posture and control in sitting on a suitable plinth with support, try and get both feet with "good" alignment on the ground. It may need towels serving as wedges to lift one pelvic side to get the trunk straight; and support with pillows for the contracted left arm in a position comfortable (contractures will need some work on too...) but if possible in some AB. With you maybe behind the patient or at one side, with your hands on sternum and Thorax its possible through slight compresion then "lift" of the thorax to lead the patient thro trunk flex/ext/latflex/rotation movements in a small range. You can also have your hands laterally on the thorax, depends on the state of the patient. Maybe you need two therapists or a relative to help.
The left foot gets input in standing, but it is possible in sitting to start reeducation in sitting by rolling the foot over your thigh(you are kneeling on the floor then) and also mobilising dorsal and plantar flexion and also the bones of the foot. Heel thumping on the floor (or also in bed when in crook lying) helps stimulate extensor activity. Extensor and abduction activity in hip and knee can be asked for with onesided bridging type exs in supine. The choice of postural positioning for various exs depends on what the hyper or hypo-tone situation is like.
Improvement depends on maany factors; age and state of patient; ammount of medication taken or other pathologies; cooperation; maybe cultural expectations in your country etc. I can't give you a complete overview of the Bobath Concept on this website, but I would advise you to find suitable up to date books on Bobath. Of course you need quadriceps, but it won't be easy and there is an immense amount of work to do in order to try and improve the patient that has been left for so long. You must also look at the upper limb, scapula etc.
Fortunately we have Neuroplasticity, we can often see improvment a long time after the cerebral insult BUT neuroplasticity allso develops in negative direction with inefficient wrong movemant patterns.
I hope I've got the message over to you, not just quadriceps!
Good Luck!

[fire_ice]

first of all thanks for such a detailed reply,absolutely there are postural changes present in the patient although sitting on both the butts the trunk has a lateral deviation towards the unaffected side which is coz of lack of trunk control as he is afraid that he might fall if he moves his trunk over the affected side,and over time it has become a fixed postural deformity and correction is almost impossible but still maintaining what ever possible range are present in the trunk with active trunk movements F/E/R.What else can u suggest for this fixed postural deformity????
Regarding the affected upper extremity,its not being left out although is has severe contractures so it is out of question to try any functional active movement so i m just trying out keep the arm in the weight bearing stretched position,hand mobilizations, splinting,some sensory feedback .so any suggestions for here??????/will scapular mobilization have any role here??????
And why i am more concerned about lower extremity is coz the patient and the carers are mainly emphasizing on walking rather than any other thing , now for the lower extremity as u pointed out the unaffected side definitely has increased tone coz of over use and the affected side disuse,i have been using ES,weight bearing using knee immobilizers but nothing is working , one more thing that i have seen is that some amount of contraction is seen in the affected side only if he simultaneously contracts the unaffected quads ,i think it is some sort of irradiation but i m discouraging him to do so , in addition to this he is doing bridging with pelvic tilting,kneeling for hip control..any suggestions here.In how much time fibrotic changes will occur in the muscle that is in disuse?????
Regards