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.

My first International publication as Co Author in Neuro Developmental Therapy Association (NDTA) Network on the net,

Thanks to Dr. Asha Chitnis, C/NDT for help and guidance in publishing the paper in NDTA NETWORK.
Participation and Participation Restrictions in a Teenager with Down Syndrome: an Indian Scenario
By by Reena Mody, PT, C/NDT, Gajanan Vithalrao Bhalerao, MPT, Sujata Noronha, PT, C/NDT Madhavi Kelapure, PT, C/NDT, Asha Chitnis, PT, C/NDT
NDTA Network  on the net November - December 2011 • Adults with Congenital Disabilities. Volume 18, Issue 6
link:
https://www.ndta.org/network/article.php?article_id=575

What to do while application of Bobath Approach?

What to do while application of  Bobath Approach?

The abnormal patterns must be stopped not so much by modifying the sensory input, but by giving back to the patient the lost or undeveloped control over his out put in developmental sequence.
The basic patterns of posture & movement, the righting reaction & equilibrium responses are elicited by providing the appropriate stimuli while the abnormal patterns are inhibited.
In this way patient the patient is given the opportunity to experience normal movement.
The sensory information of correct movement is absolutely necessary for the development of improved motor control.
Treatment therefore, concentrate on handling the patient in such a way as to inhibit abnormal distribution of tone & abnormal postures while stimulating or encouraging the next level of motor control.
 The abnormal postures & tone are controlled at key point (proximal body parts, I.e. head neck trunk, & sometimes distal parts I.e. thumb & fingers), using reflex inhibiting movement or patterns called as RIPs.
 If the patient lack s tone, sensory stimulation or tapping is used while the RIPs is applied so the is sensory inflow will not shunt into abnormal patterns.
Bobath believes that once the patient can move in & out of normal basic patterns of posture & movement he will automatically be able to elaborate on these patterns to learn the more skilled activities required in daily living.

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.

USE OF DUPATTA/CHUNARI AS A GAIT BELT IN GAIT TRAINING IN HEMIPLEGICS AND BALANCE DISORDERS

Goal is to Prevent the fall during training and walking.
While doing gait training of hemiplegics and patients with balance disorders, they are at high risk of  loss of balance and fall. During imbalance and fall we tend hold the upper limb of patients or trunk. this can lead to injury to upper limb or sometime we don't get a good grip of upper limb or trunk during the sudden imbalance. in that case we need a stable and good hook to hold and prevent the fall.
What is the solution?
In European countries and America they commonly use gait belt or transfer belt for gait training. but in India it is not commonly available in market. So i had to find a solution which is cheap and easily available. So  started using Dupatta/Chunari which all our Indian women and girls use on their dress of Salwar -Kurta. In each home this is easily available and it is free of cost.
How to use modified gait belt: Dupatta?
I use Dupatta/Chunari while balance and gait training in hemiplegics and patient with balance disorders. I tie is around the wait of patient and hold it from behind. This way patients upper limbs are free, he can use the righting reactions and compensatory balance techniques with upper to control imbalance. this way we can challenge the balance to extremes and we will be assured that the patient will not fall as we can control the imbalance and prevent the fall from the modified gait belt called as Duapatta.
I found it very easy to use , cheap/free and easily available
i suggest you also try this techniques and share your experiences and give suggestions.
PLEASE NOTE: ALWAYS USE COTTON DUPATTA AND TIE A GOOD KNOT.

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…!”