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NDT/Bobath Certificate Course in the Management and Treatment of Adults with Hemiplegia in Pune, India


NDT/Bobath Certificate Course in the Management and Treatment of Adults with Hemiplegia
Sancheti Institute College of Physiotherapy, Sancheti Health Academy, Shivajinagar, Pune, Maharashtra, India

This is the first time NDTA is conducting a ADULT NDT course in INDIA. We want maximum people to benefit from this course. But there a seats limit of 24 only. Everyone will need to apply for the course and the NDTA/course instructors will select the delegates for the course depending on their experience and accreditation in the field of adult neuro.
Course Dates:
27-01-2014 – 14-02-2014
It will be 5 days/week for three weeks. Saturday & Sunday off.

Course Number: 14A101
Course Status: Approved

Course fee- Rs-90,000/- for Indian
and $ 2000/- for International delegates

Registration fee (Non Refundable) Rs 2500/- and $ 50/- for International delegates
All the people has first aplly for registration out of which 24 will be selected.
Please send me your mail so that i can send you the registration form.

Location: Sancheti Institute College of Physiotherapy, Sancheti Health Academy
Thube Park 11/12
Shivajinagar, Pune, Maharashtra, India, 41105

Course Instructors:
Cathy Hazzard, B.Sc, MBA, PT, C/NDT CI
Nicky V. Schmidt, PT, C/NDT CI

Cathy Hazzard, B. Sc. P.T., MBA is a Physiotherapist with over 25 years experience working with adults with varied neurological diagnoses. Her clinical background also includes experience and continuing education courses in manual therapy and orthopedics. She obtained an MBA in 1993 while continuing to work as a PT. She has been an NDTA™ Coordinator Instructor in Adult Hemiplegia since 1998 and has taught introductory, certificate and advanced level NDT courses extensively throughout North America (Canada, United States, and Mexico) and internationally in such countries as Ireland, Hong Kong, Singapore, Estonia, Colombia, and Peru. Cathy practiced in Calgary, Alberta, Canada for over 20 years in the acute, rehabilitation and outpatient phases of care. She is now working in private practice and Home Health on Vancouver Island, British Columbia. Cathy served as the Chair of the NDTA™’s Instructor Group from 2002 – 2005 and a member of the Board of Directors of NDTA™ from 2003 – 2007. (http://www.ndta.org/instructor_detail.php?instructor=768)

Nicky Schmidt, PT, received her bachelor’s of science degree in Physical Therapy from Louisiana State University Medical Center in 1978. She is NDT trained in both pediatrics and adult hemiplegia and has been an active NDTA Coordinator-Instructor since 1985. Ms. Schmidt has taught NDTA introductory, basic, and advanced courses throughout the United States and Canada for 28 years. During her 33 years of clinical practice she has worked as a clinical neuro specialist in a broad spectrum of healthcare settings including acute care hospitals, short-term rehabilitation, outpatient rehabilitation clinics, home health and private practice. Nicky was an Associate Clinical Professor at LSU Medical Center in the 1980’s, is a past member of the NDTA Curriculum Committee, and past board member and Instructor Group Chair of NDTA. Currently, Ms. Schmidt is in private practice in the New Orleans area where she specializes in consultation for and treatment of adult and pediatric clients with diagnoses of stroke, brain injury and cerebral palsy.
(http://www.ndta.org/instructor_detail.php?instructor=1676)

Course Contact:
Dr. Gajanan Bhalerao
Phone: 9198 22623701
Fax: 9120 25539494
gajanan_bhalerao@yahoo.com
Website

http://www.ndta.org/course_list.php?type=AH#course283

The course details about the fee structure, eligibility, and course details will be published soon on facebook page.
Those who are interested please accept the invitation or show your interest so i will get your contact details. Then i can send you the course details as soon as it is finalized.

Thanks for showing interest.

Application for NDTA Adult Certificate course

Hydrotherapy for traumatic brain injury with hemiplegia – our challenges and solutions


Swimming pool

Swimming pool (Photo credit: Wikipedia)

This is the case of a 16 yr old boy who met with an accident leading to a traumatic head injury in August 2011. He was in a coma for 1 month after which he gradually started showing improvement. I started treating him in January 2011. He had suffered a diffuse axonal injury due to which both the sides of his body were involved.  Initially he was hypotonic on both sides and trunk . He could move his left side voluntary control grade III in upper and lower limb but no control on right side. Within next 2 months he started sitting without support, supine to sit with support and required minimum to moderate assistance for sit to stand from high bed. He could stand with weight bearing on both legs with moderate assistance. His left side improved up to grade VI. His tone in trunk &  RT upper & lower  limb started improving (grade II).

Assisted walking training on the ground

In March and April 2012 he was showing a picture of RT hemiplegia with grade II in UL & LL with developing spasticity. We used to make him walk with FRO and push knee brace on Rt (hemiplegic side). Initially with back forearm support walker then without walker. Assisted walking training was started ( we have to passively step forward the hemiplegic leg ).

English: bathing hall, Carolus Thermen, Aachen...

commercial pool training

He could move the limb in supine but could not take a step forward while walking on ground.  So we have decided to take him for hydrotherapy to improve his control of lower limb and active walking. Taking a Patient to hydrotherapy was a good idea but we do not have hydrotherapy centre/ swimming pool for patients in Pune (Except in Aditya Birla hospital). So we contacted one of the commercial pool in Kalyaninagar. We explained them the condition of the patient & our objective. Then they gave us the permission. They have given us two lifeguards to help us during training session in the pool.

We were alloted a time of 7 pm to 8pm as the pool was occupied at other times. So, the patients had to adjust accordingly as they were not allowed to come along with regular batches.

Getting in Pool (Transfer)

While going for swimming we had one more challenge of  how to take the patient in the pool (transfer)? So for that I used my Ganpati Transfer method. We made the patient to sit on the thick towel, the towel acted like a sling where the patient was sitting in the centre of the sling. Then two people were holding the towel from the sides, this helped to lift the patient easily.  After lifting the patient we made him sit at the edge of the swimming pool with his legs dangling in the pool. Then he was assisted to slide down in the pool so that he can stand in the pool. This was a very easy and safe transfer.

Swimming with help of raft

Because patient had a poor balance he could not stand in the pool and poor control of Rt (hemiplegic side) he could not swim independently. So we made him lie-down on the Raft with his trunk on the raft. Which helped to control weight of the body and arms & legs were free to move.

As he was able to move the normal upper and lower limb he started to stroking/swing them in the water which helped him to propel his body forward in water. We were assisting the hemiplegic upper and lower limb for stroking/swinging.

This is how we started swimming a patient with head injury with Hemiplegia in the water with help of Raft. We continued this Practice daily evening for about two months (6days/week)

Assisted Walking Training in Water

He was having lot of difficulty in walking  steeping forward on ground, while doing assisted walking with AFO and Long knee Brace on Hemiplegic side. so we started training of assisted walking in water, with hand support. Because of the bouyancy his body weigth was reduced and he could stand in water with minimum assistance, this also helped in stepping forward the hemiplegic leg. It was very easy for him to walk in water with less support.

We were Training him Assisted Walking on ground since 2 months but he could not step forward actively, but after training of walking in water for 1 months he could step forward on ground also with walker without assistance.

http://www.youtube.com/watch?v=bh0Cvh1O-O4

Causes and management of hyperextension of knee in hemiplegic and Paraplegic


English: Right knee.
English: Right knee. (Photo credit: Wikipedia)
Capsule of right knee-joint (distended). Later...
Capsule of right knee-joint (distended). Lateral aspect. (Photo credit: Wikipedia)

Genu recurvatum is a deformity in the knee joint, so that the knee bends backwards. In this deformity, excessive extension occurs in the tibiofemoral joint. Genu recurvatum is also called knee hyperextension and back knee. This deformity is more common in women and people with familial ligamentous laxity.

Hyperextension of the knee may be mild, moderate, or severe.

Normal range of motion (ROM) of the knee joint is from 0 to 135 degrees in an adult. Full knee extension should be no more than 10 degrees. In genu recurvatum (back knee), normal extension is increased. The development of genu recurvatum, may lead to knee pain and knee osteoarthritis.

knee hyperextension in stance


This common gait deficit occurs when the quadriceps fail to perform their customary role during loading responseand the first part of midstance.

normal grf, sagittal plane, loading response LOADING RESPONSEOrientation of ground reaction force vector (GRFV) in sagittal planeNormal GRF is located
  • posterior to ankle joint
  • posterior to knee joint
  • anterior to hip joint

What effect will this have on joint motion and muscle activation?


normal grf, frontal plane, loading response LOADING RESPONSEOrientation of ground reaction force vector (GRFV) in frontal planeNormal GRF is located
  • lateral to subtalar axis
  • medial to knee joint
  • medial to hip joint

What effect will this have on joint motion and muscle activation?


normal grf, sagittal plane, loading response During loading response, ground reaction force produces
  • a plantar flexion moment at the ankle joint
  • a flexion moment at the knee
  • a flexion moment at the hip

The body controls these moments with

  • eccentric activity in the ankle dorsiflexors
  • eccentric activity in the knee extensors
  • isometric activity in the hip extensors

compare to frontal plane


normal grf, frontal plane, loading response During loading response, ground reaction forces produce:
  • a pronation moment at the subtalar joint
  • a varus moment at the knee
  • an adduction moment at the hip

The body reponds to these moments with

  • eccentric activity in the intrinsic foot muscles and other supinator muscles to control subtalar pronation.
  • passive tension in the lateral knee structures. Active force in the tensor fascia lata could contribute to knee stability in the frontal plane
  • activity in hip abductor muscles

return to using ground reaction forces…

Visualizing ground reaction force vectors (GRFV) to understand typical gait patterns

DURING LOADING RESPONSE DURING MIDSTANCE
DURING TERMINAL STANCE DURING PRESWING

The quadriceps may not act appropriately in the event of:

  • Quadriceps weakness

  • Pain with quadriceps activation

  • Proprioceptive deficit

When the knee extensors fail to control the ground reaction force’s knee flexor moment, the person must compensate to preserve knee stability.

These compensations will likely hyperextend the knee during stance. The compensations might include one or more of the following:

  1. Substitution of another muscle in a closed chain

For example,

  • Increased hip extensor force

  • Increased ankle plantar flexor force

  1. Motions that relocate the GRF vector, changing the moment the GRF produces at a joint.

For example,

  • Forward trunk lean during loading response and midstance

  • FORWARD TRUNK LEAN IN STANCE

    during LOADING RESPONSE during MIDSTANCE

    This common gait deficit occurs when the quadriceps fail to perform their customary role during LOADING RESPONSEand the first part of midstance. This might occur in the event of:

    • QUADRICEPS WEAKNESS

    • PAIN WITH QUADRICEPS ACTIVATION

    • PROPRIOCEPTIVE DEFICIT

    During loading response, a forward leaning of the trunk produces an anterior inclination in the ground reaction force vector. Because this relocated vector passes closer to the knee joint, it produces a smaller flexor moment at the knee.

    If the GRF vector passes in front of the knee joint, it can hyperextend the knee during loading response.

    forward trunk lean during stance

    When the person leans forward with the trunk DURING MIDSTANCE, but not during loading response, quadriceps weakness or knee pain are less likely causes. Instead, it may be a compensation that helps move the body’s center of gravity forward over the stance foot. This compensation is necessary when:

    • the ankle has limited range of motion in dorsiflexion

    • plantar flexor strength is inadequate to control midstance dorsiflexion.

  • Flat Footed Initial Contact

  • Foot flat at initial contact

    typical ground reaction force during initial contact

    At initial contact, the ground reaction force vector’s point of application is ordinarily near the heel.

    typical ground reaction force during loading response

    As loading response progresses, the ground reaction force vector moves posterior to the knee, producing a flexor moment.

    flat footed initial contact

    By contacting the ground initially on a flat foot, the person moves the ground reaction force vector’s point of application anteriorly…

    so that the more anteriorly situated force vector is closer to the knee joint throughout loading response, and so produces a smaller knee flexor moment during that period.

    If the ground reaction force moves anterior to the knee joint’s lateral axis, it produces a knee extensor moment. Therefore, people may compensate for knee extensor weakness by contacting the floor with a relatively flat foot.


  1. Motions that relocate the joint axis, changing the moment the GRF produces at a joint

For example,

  • Decreased forward pelvic rotation

Hemiplegic patient have a common gait deviation during their gait training is hyper-extension of knee or  genu recurvatum.

Cause of  genu recurvatum are

1. Weakness of plantar flexors:

2. Flail foot i.e. polio, cerebral palsy etc

3. Tightness of plantar flexors (TA tendon)

Becouse of above factors patient shows a poor loading responce in gait.

In normals loading responce ankle goes from 10 degree of plantar flexon to 10 degree of relative dorsiflexion and knee in 10-20 degree of lexion. There is anterior translation of tibia over the fixed foot.

This anterior translation of tibia over the fied foot is affected due to TA tigthness.

In weakness of  plantar flexors & flail foot  if tibia moves over the fixed foot and goes in to relative dorsiflexion then this may lead to buckling of knee and lead to poor stability during loading responce to mid stance. to avoid this patient does the compansotory movement of, avoiding the anterior translation of tibia and forward lurching gait, with locking of knee. frequent use of this pattern of locking mechanism of knee during walk leads to hyperextension of knee.

Gait of RT hemiplegic Patient with genu Recurvatum

1. in case of weakness of platar flexors , . flail foot & weakness in whole limb use HIGH AFO. That is the posterior strap of the AFO is hiogh enough up the lower margine of popliteal fossa.this long leverage prevents it from going backward.

2.But this will not work in patients who walk with forward lurch posture or those who take bigger step length of opposite unaffected leg.the solution for this is very simple reduce the step length of opposite leg and allow him to step by the affected leg instead of going ahead. this will pull back the line of gravity which was falling forward to knee and reduce hyper extension.

3. In the patients having sever hyeperextension and can’t be corrected by all these measures then the last solution is use KAFO for walking.

4. knee surgery are not successful for preventing hyperextesnion.

5. In TA tightness -do stretching but the effect doesn’t last longer in the functional activity of walking. so we should give functional stretching.  for this  use modified AFO{FRO} : shift the calf bad of AFO anteriorly this produces good three point pressure phenomenon and helps in stretching the TA in functional activity of walking and helps in  reducing  recurvatum.

             

6. In cases  Poor trunk control and imbalance  or low postural tone ( Down & hypotonic CP. wok on postural tone , trunk control in addition give AFO & walker with forearm support this reduces the forward flexion of trunk.

References

1. WHO | Stroke, Cerebrovascular accident [Internet]. [cited 2010 Aug 3]; Available from: http://www.who.int/topics/cerebrovascular accident/en

2. Tapas kumar banerjee et al. Epidemiology of stroke in India. Journal of Neurology Asia.2006;11:1-4.

3. Edward R. Laskowski, M.D. Hyperextended knee: Cause of serious injury http://www.mayoclinic.com/health/hyperextended-knee/AN00283

4.Jennifer Kirkman, Yahoo! Contributor Network. Hyperextended Knee-Causes, Symptoms, Diagnosis, and Treatments

5.  what is genu recurvatum?  http://www.wisegeek.com/what-is-genu-recurvatum.htm.

6. Allison Cooper et al. The Relationship of Lower Limb Muscle Strength and Knee Joint hyperextension during the Stance Phase of Gait in Hemiparetic Stroke Patients. Journal of Physiotherapy research international.2011;(17)1.

7. Lucarli P et al. Alteration of load response mechanism of knee joint during hemiparetic gait following stroke. Journal of clinics.2007;22:813-820.

8. Susan Richardson. Assessing knee hyperextension in patients after stroke: comparing clinical observation and Siliconcoach software. International Journal of Therapy and Rehabilitation, Vol. 19, Iss. 3, 07 Mar 2012, pp 163 – 168. http://www.ijtr.co.uk/cgi-bin/go.pl/library/article.cgi?uid=90240;article=IJTR_19_3_163_168.

9. Bleyenheuft et al. Treatment of genu recurvatum in hemiparetic adult patients: A systematic literature review. Journal annals of physical and rehabilitation medicine.2010;53(3):189-199.

10. Rehabilitation, Treatment and Orthotic Management of the Stroke Patient. http://www.healio.com/orthotics-prosthetics/orthotics/news/online/%7BBDC02BFE-6C76-42E6-8457-462C3F6EC0B7%7D/Rehabilitation-Treatment-and-Orthotic-Management-of-the-Stroke-Patient

11. D. Beckers. Effects of AFO-assisted ankle angle position on dynamic knee stability in brain injured and spinal cord injured patients.ISB XXth Congress – ASB 29th Annual Meeting, July 31 – August 5, Cleveland, Ohio. http://www.asbweb.org/conferences/2005/pdf/0517.pdf

12.Prevalence of knee hyperextension in individuals with hemiplegia. http://www.google.co.in/url?sa=t&rct=j&q=causes%20of%20knee%20hyperextension%20in%20stroke%20patients&source=web&cd=5&cad=rja&ved=0CGMQFjAE&url=http%3A%2F%2Fwww.rguhs.ac.in%2Fcdc%2Fonlinecdc%2Fuploads%2F09_T025_33559.doc&ei=naewUJy4FIKIrAf94oHIAQ&usg=AFQjCNFq_n-B0tDhquU8Wkz6EhE17eWgtQ.

13.Ankara Fizik Tedavi. Assessment of Genu recurvatum in hemiplegic patients. http://www.jpmrs.org/pdf/pdf_PMJ_98.pdf

14. Knee hyeprextention in stance. http://moon.ouhsc.edu/dthompso/gait/kinetics/kneehypr.htm

Taping in hemiplegic shoulder subluxation


dislocated shoulder - study b

dislocated shoulder – study b (Photo credit: Jon Winters)

The left shoulder and acromioclavicular joints...

The left shoulder and acromioclavicular joints, and the proper ligaments of the scapula. (Photo credit: Wikipedia)

The shoulder complex consists of four separate joints, which afford it incredible mobility in all planes of motion, but at the expense of its stability.

The human shoulder joint

The glenohumeral joint (GHJ) relies on the integrity of muscular and capsuloligamentous structures rather than bony conformation for its
stability. Injury or paralysis of muscles around the shoulder complex may lead to GHJ subluxation.

Glenohumeral subluxation is a secondary complication to hemiplegia caused by a CVA, in which the head of the humerus drops out of the joint. Across the literature, anywhere from 17 to 66 percent of patients experience a shoulder subluxation after a CVA (Peters & Lee, 2003).

Patients with such a subluxation experience pain and decreased ability to perform activities of daily living. In fact, the pain caused by a glenohumeral subluxation has not been isolated. Some research even claims that shoulder subluxation is not the etiology for shoulder pain experienced post-CVA.

procedure of  taping

step 1. check the sulcus sign, and measure it. (no of finger)

step 2. check the range of movement, pain severity, end feel, capsular   tightness. record for pre and post checking for comparison.

step 3. shave the area of shoulder, scapular region up to inferior angle of scapula.

step 4. Take sticking plaster dynaplast of 4″ width. Measurement of para spinaltaping length. Measure from superior border of trapezius muscle till the inferior angle of scapula and cut the tape. Remove the polythene from the tape and stretch the tape to full length.

step 5. Postural alignment &  positioning:  make the patient stand erect so he/she gets a upright posture. correct the abducted scapula to neutral position

step 6. Stick the tape paraspinally starting from superior border of trapezius muscle up to lower sub costal area. take a note while taping that the black center line on the tape should align with the medial border of scapula. take care that there should not be any creases while taping the tape.

step 7. Preparation of second strapping of the tape. Measure from the medial tip of spine of scapula up to deltoids tuberosity level(insertion of deltoids).  cut the tape from middle up to one inch in line with black line in the middle of tape. then split it in the form of “Y” shape. then stretch it to full length.

Step 8. stick base of Y at deltoids tuberosity level. stick it in such a that the middle line of tape come over the anterior tip of acromian process. so that the half of tape  is anteriarly and half laterally  covering the shoulder for proving a better stability. out of the two strip of Y end, upper end in line of the spine of scapula and other strip towards inferior angle of scapula.

check the reduction in sulcus size

To view a video of the procedure please click on the link

  1. Griffin A, Bernhardt J. Strapping the hemiplegic shoulder prevents development
    of pain during rehabilitation: a randomized controlled trial. Clin Rehabil. 2006
    Apr;20(4):287-95. PubMed PMID: 16719027.http://www.ncbi.nlm.nih.gov/pubmed/16719027
  2. Painful Hemiplegic Shoulder.Robert Teasell MD, Norine Foley MSc, Sanjit K. Bhogal MSc http://www.ebrsr.com/uploads/Module-11_hemiplegic-shoulder.pdf
  3. S. Beth Peters1 and Gregory P. LeeProfessor2. Functional Impact of Shoulder Taping in the Hemiplegic Upper Extremity. Occupational Therapy in Health Care. 2003, Vol. 17, No. 2 , Pages 35-46 http://informahealthcare.com/doi/abs/10.1080/J003v17n02_03?journalCode=ohc
  4. Kinesiology Tape: The Little Miracle Worker (drkristakip.wordpress.com)
  5. Exercises for a Loose Shoulder – Orthopedics Doctor Houston TX (orthopedicsportsdoctor.com)
  6. Shoulder Pain (mycerebellarstrokerecovery.com)
  7. Shoulder Pain: Multi-factorial, confusing, and tiring to treat (My Rant) (jessephysio.wordpress.com)
  8. Build Big Strong Shoulder Muscles For V Shape Upper Body Build Big Deltoids (extrememuscles4u.wordpress.com)
  9. How Are You Healing Today? (ofekfamilychiropractic.wordpress.com)
  10. Shoulder Girdle: A Delicate Balance (theverticalworkshop.wordpress.com)
  11. Hemiplegic shoulder pain: defining the problem and its
    management. Bender L, McKenna K. Disabil Rehabil. 2001 Nov 10;23(16):698-705. Review. PubMed PMID:11732559. http://www.ncbi.nlm.nih.gov/pubmed/11732559
  12.  Therapeutic Taping for the Shoulder. Dr. Dyanna Haley-Rezac, PT,DPT, OCS, CSCS, CKTP. Dr. Scott Rezac, PT, DPT, OCS, CSCS, CKTP, CEAS

    13. Kinesio@Taping in Stroke:Improving Functional Use of the Upper in hemiplegic. Eva Jaraczeweska. http://www.kinesiotaping.com/images/kinesio-association/pdf/research/2006-1.pdf

    14. Strapping the hemiplegic shoulder prevents development of pain during rehabilitation: a randomized controlled trial.Griffin A, Bernhardt J. Clin Rehabil. 2006 Apr;20(4):287-95. http://www.ncbi.nlm.nih.gov/pubmed/16719027

    15. Hemiplegic shoulder pain: defining the problem and its management. Bender L, McKenna K. Disabil Rehabil. 2001 Nov 10;23(16):698-705.

    16. Arthrographic distension for adhesive capsulitis (frozen shoulder). Buchbinder R, Green S, Youd JM, Johnston RV, Cumpston M. Cochrane Database Syst Rev. 2008 Jan 23;(1):CD007005.

    17. Functional Impact of Shoulder Taping in the Hemiplegic Upper Extremity. S. Beth Peters1 and Gregory P. LeeProfessor2

     

     

Spastic muscles cant do eccentric lengthening


Spastic muscles are in the state of concentric contractions can’t do eccentric lengthening. Spastic muscles are in shortened state and active eccentric contraction in difficult. This can be due to

a. Weakness of antagonistic muscle

b. Due to reciprocal inhibition causes relaxation of antagonistic muscle

Spastic muscles act like spring that work in concentric contraction and remains in contraction mostly (flexed position) which creates motor imbalance between them and antagonist to them. Therefore strengthening antagonist assists in reducing tone of spastic muscles as this allows lengthening of spastic muscle!!

So in the initial phase of neuro rehabilitation of hemiplegic patients we should concentrate more on eccentric and static (placing reaction) contraction.

Avoid strengthening the concentric contraction. Because if the spastic muscle becomes strong then it is difficult to initiate the eccentric contraction.

During training of upper limb control we train the elbow flexion and shoulder flexion. The common mode is to train concentric contraction. We tell the patient to lift upper limb against gravity. This indirectly trains the flexor synergy make it strong then it becomes difficult to break the synergy.

So what to do? Work on placing reaction in upper limb. Place the shoulder in flexion above 90 degree and let him hold it and followed by slow lowering the upper limb (eccentric contraction).

What is the advantage of eccentric contraction? Eccentric contraction helps early and better in recruitments of motor units than concentric contractions. Eccentric contraction can generate more force with less motor unit recruitment. Concentric contraction requires more motor unit recruitment for even generation minimum muscle contraction. So it becomes difficult to initiate concentric contraction than eccentric contraction.

So in the spastic muscles we should concentrate more on eccentric lengthening. Increase in eccentric lengthening of muscles indirectly helps in reducing spasticity.

Never plan the therapeutic management based on the medical diagnosis or cause of stroke


All students and the therapists who are treating patients with stroke must have thought or heard this kind of question in their practice.

What is the therapeutic management of frontal lobe bleed/infarction?

What is the therapeutic management of occipital bleed /infarction?

What is the therapeutic management of parietal bleed /infarction?

What is the therapeutic management of thalamic bleed?

Instead of answering these questions, we need to ask different questions

What are the sign & symptoms of these patients? What are the physical & perceptual impairments of patients?

What are the activity the patient is able to do and not able to do?

What impairments are limiting the activity? What are the contextual factors & personal and environmental factors are restricting his participation?

 Neurologist does the medical or neurological diagnosis of patient’s i. e. Stroke due to infarction or bleed. Bleed or infraction internal capsule, thalamus, basal ganglion, MCA territory etc. This different level of injury and severity will helps us in finding out the prognosis and planning of treatment according to level of lesion and severity of it.

 But for us as a physiotherapist we need to look at the movement dysfunction. We need to find the physiotherapeutic diagnosis of movement dysfunction. Such as hemiplegia, henianesthesia, cognitive and perceptual disorders, unilateral neglect, heminomus hemianopia, shoulder dislocation, genu recurvatum, hemiplegic hand, claw hand, fixed flexion deformity,

 “Stoke is Medical diagnosis, Hemilplegia is a Physical diagnosis ….!”

 We treat hemiplegia neurologist treats stroke.

We need to keep in mind that we as therapists don’t treat the cause of the stroke like the medical management. We don’t plan treatment directly with the causative factors of the stroke.

We treat physical & functional dysfunction –  “MOVEMENT DYSFUNCTION”.

We plan our management according to:-

  • What are activities limitations?
  • What impairments (signs and symptoms) of patients causing activity limitation
  • What is the need of the patients according to their lifestyle, age and occupational demands (personal & environmental factors, contextual factors)?

Any patient of stroke with any medical diagnosis the physical functional demands from life are same. These demands doesn’t change with diagnosis ( the prognosis & the ability to achieve these target might be affected due to level of lesion and severity of lesion).

Every patient basic physical functional demands from life are: -

  1. Bed mobility- rolling supine to sit, bed side sitting etc
  2. Toilet training
  3. Transfers from bed to chair or toilet transfers
  4. Sit to stand
  5. Standing with or without assistive devices
  6. Walking with or without assistive devices
  7. Upper limb function for hands skills & manipulations
  8. Activities of daily living (ADL) & Instrumental Activities of daily living (IADL)- dressing, feeding, brushing, combing, reading writing & bathing etc
  9. Indoor and outdoor ambulation with or without assistive devices
  10. Stair climbing

 These activities will be required to train in patients. We need to ask questions how to achieve these activities with current level of impairments and contextual, personal & environmental factors. Plan the gaol according to the activity & participation restrictions. Train the patient for his desired activity. Involve him in planning the treatment program. Ask him which activity he wants to learn first. Take his view point in account and set realistic, challenging but achievable goals. And plan the management according to it & try to accomplice that activity. Treat those impairments which are limiting the activity and his participation in community. He may have multiple impairments but not all the impairment limits the desired activity of the patients and his physical and functional demands in his lifestyle.

 To get the right answer for the management you need to ask the right question….!

If you ask a right question you will get the right answer for it.

Your main objective should be changing the participation and activity limitation in community (based on ICF model).

 “Our treatment should bring some change in his life and not in the impairment…!”

 

Every patient of thalamic bleed doesn’t show symptoms of thalamic syndrome…!


 Most of the patients with thalamic bleed don’t show the typical symptoms of thalamic syndrome or thalamic pain. These bleeds are around the basal ganglion and internal capsule so they do show signs of hemiplegia and some will show signs of hemianesthesia on opposite side of body. We assume that every patient of thalamic bleed will show signs and symptoms of thalamic pain but that’s not always true. We need to look at bleeding near thalamus or around basal ganglion with broader view.

DO NOT STRETCH CALF (TENDO ACHILLES TENDON) TIGHTNESS If IT DON’T HAVE GOOD STRENGTH IN PLANTAR FLEXORS


DO NOT STRETCH CALF (TENDO ACHILLES TENDON) TIGHTNESS If IT DON’T HAVE GOOD STRENGTH
Most of the neurological cases presents with calf (Tendo Achilles tendon) tightness i.e hemiplegic, paraplegic, cerebral palsy & Parkinsonism. On routine examination we come across mild to moderate TA tightness. And common line of treatment is TA stretching. But very few people take strength of plantar flexors in account. If we stretch a muscle which is already weak & unable to hold the body against gravity then this will lead to crouch. The person who was able to maintain the ankle in 90 degree and stabilize the body in standing due to tightness of TA, will not be able to maintain ankle in 90  degree  and this will lead to relative dorsiflexion ankle and knee flexion which caused as crouch. More the crouch lead to more flexion of hip knee and ankle this causes postural instability.

KEY ELEMENT AND PINICPLES OF NEURO REHABILITAION


We should always treat in upright positions

work on

Alignment

Reactive postural control

Righting reactions

Postural adjustments

Adaptive postures and reactions

Change BOS first then COG then orientation or alignments

We should always work at the end  limit of stability. it should be just enough to challenge it. Not too much out of LOS or too short.

During reach there should lengthening on the side of reach out & weight shift and shortening on the opposite side.

Don’t change the orientation too much. there should be short range of excursion.

Always work in the outer and middle range then progress to inner range of movement.

Always work with the knowledge of result than knowledge of performance for feedback.

Reach out should be just enough to challenge the limit of stability.

Avoid ballistic stretching to prolonged sustained stretching and functional stretching.

Adaptive tightness- can be due to contractile and non contractile element.

MOTOR LEARNING PROGRAM(MRP): MRP provides practical guidelines


Carr & Shepherd, Australian physical therapist, among a growing group of physical therapists , occupational therapist  & movement scientist (who apply principles of motor learning to practical rehabilitation intervention for people with motor difficulties due to CNS dysfunction. Clients who demonstrate potential to improve motor control decrease the opportunity to learn to perform motor task with efficiency, fluidity & versatility.

MRP provides practical guidelines for the following:

  • Assessment of motor function during task performance
  • Analysis of motor performance to determine key limiting factors that are amenable to change through therapeutic intervention
  • Prevention or reduction of these key-limiting factors through direct intervention and client education.
  • Design  to be used as therapeutic challenges that stimulate development of effective movement strategies
  • Adaptation of the physical environment to promote maximum function by each individual.
  • Assistance for individual in developing strategies for approaching & mastering the motor challenges of new activities they may wish to perform in the future.