Causes and management of hyperextension of knee in hemiplegic and Paraplegic

English: Right knee. (Photo credit: Wikipedia)

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.

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.

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

Spinal Cord Injury Rehabilitation workshop organized by Indian Association of Physiotherapist Pune Branch and Sancheti Institute college of Physiotherapy, Pune

Indian Association Of Physiotherapy Pune Branch & Sancheti institute College Of Physiotherapy organized a workshop on SPINAL-CORD INJURY REHABILITATION  on 27^th and 28^st October  2012 . Course instructor was Dr. Gajanan Bhalerao (PT) MPTH Neuro, Associate professor, Sancheti College of Physiotherapy & Inchargeof Department of Neuro and Spine Rehabilitation Sancheti Hospital, Pune.

In this course 32 students from all over Maharashtra Physiotherapy colleges & clinical therapist attended the work shop. The workshop was inaugurated By Dr. Meenakshi Pandit, Convener IAP Pune branch, along with Dr. Apurv Shimpi Treasure Executive Committee   Member Dr. Anushree Phansalkar IAP Pune branch.

We had Invited Major Bist, administrator director Paraplegic Rehabilitation Centre Kharaki, Pune to give information the functioning and activities of paraplegic at their centre.  Pararaplegic are living at the centre and all of them are independent in their lifestyle and earning livelihood through vocational rehab.

Dr. Vijay Gupta MPT neuro (USA) was also helped during the practical session for supervising the particiapnt practice of practical demos done in the workshop.

           

The workshop included the neuro anatomy, mat exercises, transfer training, ambulation training etc. Participant were taught how to set the goals according to level, severity and available period of admission, OPD bases taking into account his lifestyle, contextual and environmental factors in his own home/village/town/city.

Practical demos of treatment on patients  was shown. Different techniques of facilitation voluntary control/strengthening was demonstrated on patients with incomplete cord injury TYPE B/C/D/E. Two quadriplegic who were showing type A in first few months were called in the workshop who are now high functioning walking independently, driving two wheelers with added two wheels independently .  Car transfers’ training of patients was shown. Indications and contraindication of different orthotics and prescription of orthosis taught .   

                                                                                                         Modified bike for para

car transfers

Car modifications

Workshop details

Day 1 Saturday -27th /10/12

Registration and breakfast

Introduction Overview of anatomy of spinal cord Incidences of SCI Classification of  SCI Clinical syndromes Physical effect of spinal cord injury Levels of injury & functional abilities

Physical therapy evaluation and goal setting; ASIA scale

Functional goals & Strategies for functional rehabilitation

Case Studies

Evaluation

Day two Sunday - 28th/10/12

Assessment, prescription & Wheel chair ambulation training

PWB Treadmill Training role of Central pattern generators(CPG)

Orthotic prescription

Stair case climbing training

Gait training.

Bladder and Bowel training

Bed sore prevention

Role Of Stem Cell Therapy

Participant's Feedback on course content and training was taken at the end of both day. All the students like the detailed anatomy and its clinical apllication, differential diagnosis & classfication of different spinal cord injury. Every learned a lot from the lab session of ASIA assessment on patients.  On post workshop feedback all the participaants reported that, they leanred lot of new techniques of faciltation, multiple alterantive methods for bed mobility, transfers and ambulation training, wheechair modification, Orthotic fixation, and Role of steam cell in SCI rehabilitation. Everone extreamely satisfied.

STUDENTS PARTICIPATED IN WORKSHOP

S. NO.	NAME	STATUS	PLACE
1	RADHA AJAY MEHTA	PRACTICE	MUMBAI
2	NEHA MANJUNATH	PRACTICE	MUMBAI
3	JUIE MESVANI	PRACTICE	MUMBAI
4	HETAL JITENDRA SHAH	PRACTICE	MUMBAI
5	HIRAL PRASHANY SAMPAT	PRACTICE	MUMBAI
6	DEEPMALA DINESH SHARMA	PRACTICE	MUMBAI
7	DARSHINI VIJAY DESAI	PRACTICE	MUMBAI
8	SNEHA JADHAV	INTERN	PUNE
9	MANALI DEVANE	MPT	PUNE
10	RUCHITA KOTEWAR	MPT	PUNE
11	SURYAKANT GADGERAO	MPT	PUNE
12	TUSHAR DHAWALE	MPT	PUNE
13	MRUNAL HARLE	MPT	PUNE
14	PRATIBHA SALKAR	MPT	PUNE
15	ARCHANA GIDWANI	PRACTICE	PUNE
16	SADHANA	MPT	PUNE
17	PURTI	MPT	PUNE
18	RASHMI	MPT	PUNE
19	NIMISHA MISHRA	MPT	PUNE
20	SANNA SAYED	PRACTICE	MUMBAI
21	SHARDA BHALERAO	INTERN	PUNE
22	CHETANA AHER	INTERN	PUNE
23	JAY PAWAR	PRACTICE	PUNE
24	ABHA BHUTADA	PRACTICE	PUNE
25	RAJASHREE FADNAVIS	MPT	PUNE
26	APOORVA PHADKE	PRACTICE	PUNE
27	ASHWINI KAMBLE	PRACTICE	PUNE
28	NITIN CHOUKE	MPT	PUNE
29	CHANDALI DOSHI	MPT	PUNE
30	HARSHIKA BHANUSHALI	INTERN	PUNE
31	SNEHA MULE	PRACTICE	PUNE
32	DENZIL FERNANDES	PRACTICE	PUNE

Basic Neuro-Developmental Treatment (NDT Paeds) workshop in November -December 2012

Indian Association Of Physiotherapy Pune Branch &  Sancheti College Of Physiotherapy Pune

Organizing a workshop on

Basic Neuro-Developmental Treatment (NDT Paeds)

Course Instructor- DR. ASHA CHITNIS MPT, NDT paeds

This is an exciting and intensive training course for physical therapists, occupational therapists, and speech and language pathologists comprised of both theoretical and practical work. The material presented in the course is based upon the theoretical and practical concepts developed by Dr. Karel and Mrs. Berta Bobath and conforms to the standards established by the NDTA, Inc.

This course will be held at Sancheti Institute College of physiotherapy,Shivajinagar, Pune & Sancheti hospital Shivajinagar, Pune. Please note that this is an intensive weekend format (Saturday  & sunday) on 24th & 25th November and 8th & 9th December 2012. The number of days in class will total 4 days with class running between the hours of 8:30 am and 5:00 pm. This course curriculum is outlined to include a minimum of 24 hours, inclusive of lectures, group work and presentations, discussions, demonstrations, and patient treatment.

The course will cover: fundamentals of NDT philosophy; neurophysiology as it relates to NDT; typical and atypical movement development; fine motor development and sensorimotor aspects of development of functional skills, typical and atypical development of upper and lower extremity  and the progression through space, including gait; and treatment principles and application.

The course is limited to a total of 30 therapists, including physical therapists, occupational therapists,

The course contents 
(1) Motor control & it's clinical Reasoning
(2) Normal & Abnormal Development
(3) Evaluation of child with CP
(4) Guiding Principles of treatment
(5) sensory Processing & NDT
(6) handling treatment Principles & Demo

Who can attend?

1. All the clinical therapist interested in peads (PT &OT)

2. Interns BPT

3. Master of physiotherapy

4. Master of occupational therapy

Why to attend this course?

1. NDT bsci course will help the therapist interested in Neuro & peads in understanding motor control, normal and abnormal development, Evaluation of children with Cerebral Palsy.

2. This course helpfull for all the MPT/MOT students in the masters programe because each master has to study motor control, normal development and neurotherapeutic approches. This course will help them in better understanding.

3. The course in Pune is organised in a educational institute who has very good infrastucture with AC rooms which helps us in keeping the course cunduction cost less compared to the course organized in 3-5 star Hotel in Mumbai (cost of event and food is very high in Mumbai).

Numbar of seats awailable =30

Course fees = Rs 5000/-

Venue = Sancheti College Of Physiotherapy Pune

Contact : Apurv Shimpi (Treasure of IAP Pune branch) 9890183195, apurv008@gmail.com

Or Gajanan Bhalerao -9822623701 gajanan_bhalerao@yahoo.com

I got the best teachers award in the students survey conducted by sancheti healthcare academy for college of physiotherapy

First time  Sancheti Healthcare Academy  conducted  students survey for college of physiotherapy. this survey was done  by Dr. Priya Ramachandran Master’s degree Business management ( Gold medalist ) MA Economics. professor of PGP-HS (Post Graduate Programme in Healthcare Services) and PGA- HS (Post Graduate Advanced - Health Services). under the guidance  of Mrs. Manisha Sanghavi, executive director of Sancheti Healthcare Academy.

Sancheti  college of physiotherapy is third in India she wanted to find how who can make it number one in India. this one of the step in the process of it.

 Mrs. Manisha Sanghavi, Executive Director wanted to find out 

• how students learn in sancheti  college of physiotherapy. ?
• what methods of teaching they understand more and like more. ?
• what methods they want to incorporate in training and education of students. ?
• students suggestions
• There was students poll on the teachers teaching methods and their learning.  on the bases of students poll there was ranking done. 

Dr. Priya presented a full research report of 70 -80 pages with statistic. the result of research included what student's best methods of learning, what they feel most important and least important in training of physiotherapy.  Ranking of teachers according to students learning. 

In this survey

Dr. Gajanan Bhalerao got the First best teacher Award

Dr. seemi Retharekar got second  best teacher Award

 

Dr. Vivek Kulkarni got Third  best teachers Award  

TILT TABLE STANDING: early weight bearing and standing in patient with Total Hip Replacement with complications.

TILT TABLE STANDING:  early weight bearing and standing in patient with Total Hip Replacement with complications- para paresis, diabetic, high BP and cardiac problems.
This is patient with Total Hip Replacement rt side with bilateral lower limb weakness and trunk weakness. she was unable to stand on her even with walker. so we have to make her stand with help of tilt table. give her feedback of upright standing and weight bearing through legs. to improve the postural reactions and  to keep her engage in active participation patient is given a activity of ball catch and through. after few days of standing we made her stand with bilateral knee brace and walk with forearm support walker. initially we have passively start stepping forward for her. slowly she learned to take steps with help of walker with minimum assistance.

please click here for details of video

video will be live at: http://youtu.be/TbrKFsORYd0

SCI REHAB: Modified prone push up in high Paraplegics & Quadriplegics with weak triceps

Modified prone push up in high  paraplegics - who have weakness in trunk and unable to do push up for upper limb strengthening. in that case we can put a big bolster under the chest and  raise and support the upper trunk on the bolster that will help him balance and control the upper trunk and could put more efforts in prone push ups and help in strengthening of upper limb.

Quadriplegics with weak triceps also have difficulty in prone push up also can be benefited by this technique.

 please check the link of video
http://youtu.be/uNeEBhyyHUI

I HAVE COMPLETED FIVE YEARS IN SANCHETI COLLEGE OF PHYSIOTHERAPY AS A ASSISTANT PROFESSOR/ LECTURER.

Dear friends,
at the end of marc 2012 i have completed my
FIVE YEARS IN SANCHETI COLLEGE OF PHYSIOTHERAPY PUNE, INDIA
AS A ASSISTANT PROFESSOR/ LECTURER.
It unbelievable that i complete five years. what a journey….! i was a great experience. when i look back there are many more milestones and achievements i could do in and due to sancheti college of physiotherapy. 1. PUBLICATION:- i could done two publication (1 international -NDTA NETWORK and 1 national Journal of orthopedics and rehabilitation). Preparing for next 4-5 publications this year
2. RESEARCH PAPER PRESENTATIONS & AWARDS:- INTERNATIONAL
a.Winner Of Young Presenters Scholarship From Epilepsy Foundation India, in the conference of“International congress on neurology and rehabilitation Goa April 2010”,
STATE LEVEL:
a. Winner of best paper award in engeering and technology category In Avishkar 2010 of Maharashtra university of health sciences (MUHS), Nashik India.
b.WINNER OF BEST PAPER FOR scientific paper presentation in AVISHKAR 2010 of Maharashtra University of Health Sciences (MUHS), AURANGABAD, India.
3.REESOURCE PERSON/COURSE INSTRUCTOR:- I have conducted Conducted workshop on
a. 2D & 3D Gait Analysis and its Management
b. two workshops of MOTOR RELEARNING PROGRAM- for stroke rehab
c. two workshops of Spinal Cord Injury Rehabilitation
4. Development of new NEURO DEPT thanks so sancheti hospital and sancheti healthcare academy
5. SUPPORT GROUP: we have started with Spinal Cord Injury Rehabilitation, and very soon we will start stroke, Parkinson and brain injury.
6. i got opportunity to treat DADA J. P. VASVANI.
7. May be this academic year i will be a post graduate teacher and i will get opportunity to guide 2 PG students and be a READER.
8. Be a imp part of scientica- students conference.
I am very thankful for support of
Dr. K. H SANCHETI, MS ORTHO, founder chairman, Sancheti hospital.
DR. PARAG SANCHETI, MS ORTHO,  chairman, Sancheti hospital.
MRS. MANISHA SANGHAVI, executive director, Sancheti healthcare Academy
DR. S. M. SABNIS, EX PRINCIPAL, Sancheti college of physiotherapy,

DR. S. A. RAIRIKAR, PRINCIPAL, Sancheti college of physiotherapy,

DR. NILIMA BEDEKAR
DR. VASANTI JOSHI,
DR. VIVEK KULKARNI,
DR. RAZIA NAGARWALA,
DR. APURV SHIMPI,
DR. SEEMI RETHAREKARDR.
and all the consultant and staff of
Sancheti college of physiotherapy,
Sancheti healthcare academy and
Sancheti hospital. Thankful to all students for giving me opportunity to teach them and making me COMPLETE TEACHER.
THANKS TO MY FAMILY

There is a big difference in stretching and lengthening

In lengthening we just take the muscle to the normal length of the muscle which is the elongated state of muscle. i.e. extrafusal msucle fibers are put in the lengthen state from the lax state{ we just take the slag out} so that the intrafusal muscle fiber are elongated and the muscle spindle also under some degree of tension.
This is the optimum length of the muscle which helps in effective facilitation of muscle. this is what the Frank Starling law stated ” The length of muscle is directly proportional the strength of the muscle.” in this optimum length there are maximum number of cross bridges are available on actin and myosin filament for contraction ( walk along theory }.

where as in stretching we are not bothered about the optimum length of muscle but we ant get the normal range of the joint and length of the muscle even if the muscle has strength or not to maintain and work in that new length.

during this kind of stretching specially the spastic muscle we don’t get the change in the length of the contractile element of the muscle, instead we stretch the non contractile muscle. this will over lengthen the muscle and put under mechanical disadvantage and sometime changes the angle of pull of muscle.
all these abnormal stretching and mechanical disadvantage of muscle will reduce the strength of muscle make it permanent weak.
example over stretching of quadriceps or long flexors of hand put them in inefficient length or position. and what we call this condition as EXTENSION LAG in quadriceps. i will explain this in more details with diagram in new blog.

HOW TO DO WALKING TRAINING WITH WALKER IN PATIENTS WITH ASIS TYPE C QUADRIPLEGIA WHO DO NOT HAVE HAND CONTROL TO HOLD THE WALKER DUE TO LMN LESION AT C7, C8 & T1.

Quadriplegic patients who have LMN lesion at C7, C8 & T1 do not have hand control and are unable to hold the walker.  In spite of improvement in lower limb and trunk strength these patients are unable to walk with walker because they can’t hold the walker.

So what is the solution?

The solution is very simple. When they are not able hold the walker due to hand weakness we can use forearm support walker for gait training.

www.gajananbhalerao.wordpress.com/2011/12/09/how-to-do-walking-training-with-walker-in-patients-with-asis-type-c-quadriplegia-who-do-not-have-hand-control-to-hold-the-walker-due-to-lmn-lesion-at-c7-c8-t1/

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.