Quadriceps activation!!!!!1

[fire_ice]

hello,
i have a patient with left side stroke , had stroke 2 years back and just recently came for physiotherapy at my centre , absolutely no contraction in quadriceps as such he is unable to stand ,no hip control got some activity in the plantarflexors, i have been trying hard to initiate the contraction in the quad.but all in vain does anybody have any suggestions which will be worth trying.
Regards

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[Canuck Physio]

Firstly, can they complete inner range quads?

Is there hip activity?

If so,

IN sitting have you tried straight leg raises (I mean proper sitting with back support)?

Can this be done? If so try to progress this as it will also require quads for recruitment.
Add Ankle External Rotation for greater focus on the VMO.

[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

[usit]

Have you tried the following to activate knee extension:
1) patient sitting with feet above floor, no surface contact. PT about 2 m in front, roll a ball (beach ball to start with, very light) towards the weak leg and tell patient to kick. If no reaction first time - do it again, at least 20 times before you give up. If reaction - change into heavier ball, Bobath-ball, which makes it obvious to the patient (and his brain) that more force is required. Many repetitions.

2) use a vibration plate (cheap ones have not been proved to be less good than expensive ones). Begin in a sitting position and put the affected foot on the plate. Tell the patient not to allow the foot to slide off the plate during vibration, (eg 30 Hz/30 secs). Do 5 repetitions.

3) standing with the affected leg on the vibration plate. You need to stand the non-affected leg on a low stool or similar of the same height as the v-plate to make it possible to do weightbearing over the affected leg. Use same dosage as above.

4) stand the patient on two bathroom scales with the scales in sight so he himself can keep an eye on the numbers. Tell him to put weight on the affected leg and increase the amount on the scales under the affected leg and decreas under the other.

In general - lots of coaching, other patients in the gym encouraging, applause with positive results, aso. I have tried this on a few patients with log standing paralysis on the affected leg and it has worked in the end. Requires a hard working PT with great ambition AND a well motivated patient!

Good luck!

[Judith Mollet]

The V plate sounds interesting, any published info on it's use with stroke patients around?
Back to this patient. Stroke patients do not always get anywhere fast! Keep cool about "nothing is working". You cannot work miracles in one month. How often can you treat in a week? how long at a time? The relatives wishes are valid. But often unrealistic. If the wish and long term goal for them is walking, OK. Accept it. But you are the expert as far as therapie goes. Do standing, weightbearing, but explain as good as they can understand that you have to improve other functions in order to help the patient on the way. We know a quick fix is not possible.
I don't know how old the patient is. If joints are stiff, you might be able to improve it or maintain it. Be realistic. Careful manual work on joints and soft tissue is not totally forbidden in stroke patients but I don't have the patient infront of me to suggest in detail. (does he have anticoagulant medication?)
What is the UpperExtremity weightbearing stretch position? If functional activie movement is not possible, and some maximally assisted/passive movement combinations are, then do them and encourage the patient to look at the hand and arm moving. Arms are not just for weightbearing in every day. They are used to express oneself, take and hold and give things. Put some really interesting thing in front of him and motivate him to reach it with your help. Assist lead his arm and hand, if at all possible if hypertonus allows, towards the object, try and get him to get there at the 2nd or 3rd attempt. This would include some trunk participation maybe. Short distance, small achievment. Yes of course scapula awareness is also useful. Proximal positioning is needed for distal precision work. (I know this person can't ) Mobilize for example by reaching with your hands around the sitting patients upper body, one hand ventrally other dorsal approx under the armpit to elevate the shoulder girdle (sorry impossible to explain in short) incl. scapula with either emphasis on pectoralis or lat dorsi soft tissue mobs. If you don't have much time to treat, I would suggest leaving out the electrostimulation and do more active-assisted/ movement facilitation. It may be usual to do it in your country, but I'm convinced active hands on movement brings more. We don't do any here in the Bobath courses. We often do not get anyway near perfect movement in longstanding strokes. Often we have to accept the hyperextension trick movement without proper quads in the knee, if it allows a way of walking at home that relatives can deal with and it makes the quality of life and managment better. Not ideal but thats life as a physio.
Keep on trying, you have done lots of homework on this one. You should see some progress sometime.

[Fyzzio]

Hi,
to look at it from a completely different aspect:
- have you considered Community Physio = someone who sees him at home to check which appropriate transfers/ exercises etc. he can do in his home
- he also sounds like he definitely needs OT input; all your efforts are not going to be worthwhile, if they are not transferred into ADLs/ PADLs; also OT could help with starting cognitive rehab, which will allow you to work more effectively with your client.

Good luck,
Fyzzio

[usit]

Hello again,
How often and how much? I work for an organisation lead by very qualified neuroscientists and we do intensive rehab courses for strokepatients and their carers. We do strengthening, balancing, coordination, modified CI-therapy for hand and legs, vibration training (excellent for stretching contractures, for increasing proprioceptive input in legs without sensation and for muscleactivation) a s o. Our patients have chronic stroke (6 months - 7 years sofar) and they receive 60 hours training in 3 weeks (4 hrs/day, mon-sat). I have worked within the National Health System in Sweden for over 30 years and with this organisation since 2003. We have very good results of a kind that I never experienced in traditional (Swedish) strokerehabilitation and I feel very eager to spred the word! I apologize if I sometimes become a bit too enthusiastic...but I just wish all physios could experience the difference with this approach. Everything we do is, as far as we can see, evidencebased or at least described in the literature. We do not create wonders but this amount of training really brings out all resources that the patient has.
We are right now making plans for publishing our results.
What I really wanted to say was - work them hard! If there are no heart problems or other health problems - work them hard! They will make progress and they like it! It is not dangerous to get out of breath or have sore muscles and spasticity will not increase permanently even if it does during the physical effort. Unfortunately, we cannot give them enough training within the National Health System but if we get used to and accept the way things are and stop trying to break way for new knowledge - nothing will change. And wouldn´t that be sad...

About vibration - check out "whole body vibration" on the PubMed to begin with.

Thank you for allowing me to take part in this discussion!

[usit]

About intensive training for stroke at Swan Rehab in USA.

Abstract Publication 17401 - PT 2008 June 11, 2008 June 14, 2007

Regards,
Bo

[fire_ice]

Hello all ,
i really appreciate all ur feedbacks, regarding how the upper limb looks like i tried to attach a picture but the file is too big.Let me describe u the condition of the upper extremity,Starting from shoulder , no shoulder control,limited passive flexion and extension , almost no external rotation ,produces pain in an attempt to move (so cant move), trying scapular mobilization and pectoral stretch.... Elbow severe flexion contracture (may be spastic also but contracture is a bigger problem)with pronation ,wrist flexed,fingers curled in ..attempts to move the wrist/fingers in passive extension impossible....elbow cannot be extended beyond about(full flexion to 30 extension) ..... .so what i m asking is , if the arm is completely non functional and in such a bad shape what can be done...the patient is not interested for serial casting...

Regarding the lower extremity, there is not limitation in hip/knee flexion and extesion(passive) anlke (limited dorsiflexion) end range... patient is M/52 ,well build.......
Regards

[Judith Mollet]

OK, not sure exactly how limited you mean by your innacurate description but it's enough to give an idea. Try side lying on better side with enough pillows etc under the stroke arm to support it without forcing movement in directions it can't go in, and in a "neutral" position. Support top leg with pillows, therapy block or whatever. Try raising awareness of thorax and scapula by hands on stuff. "mark" the outline of scapula with your fingers; have your hands on the thorax to feel and reinforce movements of respiration. Passive movements of scapula. See what happens to the rest of the upper limb. From in front of patient, one hand on upper humerus and helping with maintaining slight approximation and slight ex. rotation (just whats possible) of GH joint, assist scapula with arm protraction..then retraction, maybe some is possible. See what assisted movements and gentle stretches of the arm are possible in whatever position of the body is best for lowering the increased tone.
I've also tried unilateral PA's in side lying with stroke patients for Thoracic mobilisation and increased sensory input. Trunk movements in side lying might be very suitable for loosening the arm. Rotation thorax/pelvis I'm sure you've tried already. As for fingers and hand, go gently for the small amount of extension/flexion you have and repeat it. Sometimes by "marking" thenar and hypothenar eminence in longitudinal direction with a spatula or similar one can get a bit of release in the hand. Or stimulation of inner small finger side of hand. Gemtle massage and squeezing of thumb adductors and massage of space between metacarpals can help as well. Depends on patient and pain reactions. Don't give the arm up completely as weird feedback from arm influences trunk and the rest but it sounds pretty bad and I guess won't be functional. I wouldn't start on serial casting either. Be careful with shoulder to avoid a nasty painful one, maybe relatives should also take care whilst dressing and doing transfers. Just do what you can, remember. No quick fixes!

[fire_ice]

Thanks again !!!!ya i have been doing mobilization of hand and scapular mobilization with some elbow stretches..but as u said hard to make it functional again.... Why u said that u wont think of Serial casting , i think that this is the only possible way thinks can be corrected to what ever extend possible.
Regards

[physiosanskrati]

Read your query regarding q-activation.
What i feel is you should try some basic and simple concepts like
PNF-
1. Activation of motor unit depends on stimulation of AHC.
2.The threshold of the cell is reduced by repeated bombardment.
3.When normal pathways are permanently blocked the use of alternative pathways can be developed.

What can be done practically-
1.Try stimulating sensory receptors.
2.Ask him to contract the normal quad with max resistance possible & simaltaniously contract the affected quad.
3.Practice static quad ex in prone.