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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

HOW TO IMPROVE AROUSAL IN PATIENTS HAVING COMATOSE STATUS OR LOW SCORE ON GLASGO COMA SCALE?


Patients with brain injury or stroke patients with loss of consciousness they have multiple problems. Major problem is loss of consciousness, less arousal and alertness. Along with loss sensory motor control. Coma stimulation program emphasis on use of sensory stimuli of different nature. Such as use  of auditory stimuli, olfactory, visual & somato sensory stimulation. These multiple stimuli works but it takes lot of time and slow process. The stimulation or arousal doesn’t persist longer.

During my experiences of treating these patients with brain injury and comatose patients.  I learned that stimulus better and lasting result follow

 

 PRINCIPLE OF TREATMENT

1.We have to give multiple sensory stimuli simultaneously

2. Stimulus should be able to stimuli larger area of body.

3. Work more on righting reactions.

4.Work reactive postural control stimulation

5.Target more on improving head control and postural control.

6. Work in upright position such as sitting or standing.

I GOT BEST RESULTS WITH

7.Working on bed mobility- initially when patients are not able to do it. Do repetitive passive rolling, supine to prone, supine to rolling to sit.

8. Standing – passive standing with maximum support. Either on tilt table or standing with 2 persons support. Use knee support and ankle foot orthosis (AFO).

9. Walking training- start early ambulation. Initially we have to passively assist him in walking.

The key of effectiveness of these techniques are involves the principle of treatment from 1 to 6.

This helps in multiple sensory stimuli, postural control training in upright position, improves reactive control and righting reactions of body. This ultimately improves arousal & Improves motor control and postural control of body.

Nature of handicap of patient with brain lesions:: Bobath Approach


Nature of handicap of patient with brain lesions

 1. Neurophysiological considerations.

  • The physical handicap resulting from a lesion of the upper motor neuron is seen in terms of an interference of normal postural control.
  • We are dealing with abnormal coordination of motor patterns.
  • If we speak of ‘patterns of coordination’, we mean the pattern of normal& abnormal postural control against gravity.

 2. The fundamental problem

  • Abnormal patterns of coordination in posture & movement
  • Abnormal qualities of postural tone
  • Reciprocal innervations.

 3. Abnormal postural reflex activity

  • Associated reactions
  • The effect of released asymmetrical tonic neck reflex activity.
  • The effect of released positive supporting reaction.