Mamangment of hyper-extension of knee or genu recurvatum inHemiplegic patient

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. 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 hte patients having sever hyeperextension and canr be corerected 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

Most of the time the hyper extension of knee is not because of quadriceps weakness in hemiplegic patients

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 platar flexors
2. flail foot
3. TA tightness
4. weakness in whole limb.
5. Poor trunk control and imbalance  or low postural tone ( Down & hypotonic CP}
6. bigger step length of opposite unaffected leg.
u must be surprised to know that the cause is not quadriceps weakness.
most of the time the hyper extension is not because of quadriceps weakness.

 In all above causes the patient is unable to keep the knee straight during weight bearing and they tend collapse with knee flexion. in order to prevent the knee collapse they lean forward and keep the line of gravity anterior to the knee.

In case of TA tightness it pulls the  knee in hyper extension.

In order walk fast hemiplegic patients learn to take  bigger step length of opposite unaffected leg. this cause riding of the femur over the fixed tibia causing hyper extension.

TO LEARN NEURO REHABILTATION, IT IS IMPORTANT TO LEARN THE PAEDIATRIC REHABILITATION

During my practice of neuro rehabilitation of adult, i understood that the better i could understand and manage a baby with cerebral disorder, i got better understanding of management of adult neuro case.
In children with cerebral palsy, and small baby's who do not understand us and cant follow the command, itself it is a big challenge to treat them in this situation.
whole management of C P children is on the handling of the baby and stimulation of of the all the postural reactions, reactive postural control and their postural adjustment to the handling is the key factor for management of patients with neuro problems.
The normal development of baby, setting of the goal according to the physical ability and age is the guideline for goal setting. It teaches us to keep patience which is very important in management of neuro patients.
i suggest all the therapist who are interested in neuro rehabilitation they should emphasis on learning the paediatric or cerebral palsy rehabilitation first. this will give u better understanding of the neuro.

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.

ANY SENSORY STIMULUS WHICH IS NON PURPOSELESS IS USELESS

During sensory facilitation in neuro rehabilitation we use tapping, weight bearing, and joint compression to facilitate the motor control in upper limb. Most of the time therapist use weight bearing through upper limb either in prone on elbows, quadruped, or in sitting weight bearing through upper limb with hand kept either sideways or backward. Most of the time we don’t even think what is our objective of this exercise and which purpose it is used. Even we don’t plan that, are we trying to do heavy joint compression or light joint compression. What is the purpose of the joint? Is it heavy joint compression or light joint compression? Wrist and elbows are not meant for heavy joint compression. Wrist and elbows are for the purpose is for light activity and skillful activity. By doing this heavy joint compression in the lengthened range of ling flexors, we overstretch the long flexors. This increases the movement arm of flexor tendons and this cause’s excessive flexion force and flexion attitude of the flexors in every movement of wrist and hand and skillful movements. Already it is difficult to activate finger flexors and teach release of fist and this over action of flexors makes it more difficult. So we should avoid weight bearing through hand in fully extended fingers.

Instead of giving sensory stimulation in functional positions we need to give sensory feedback during functional activity & task specific position. This helps in sensory integration of sensory feedback with motor control in given task, given task parameters and contextual factors.