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

http://gajananbhalerao.wordpress.com/2011/12/07/do-not-stretch-calf-tendo-achilles-tendon-tightness-if-it-dont-have-good-strength-in-plantar-flexors/

How to carry out ambulation training with KAFO in patient with a spinal cord injury who had an added complication of an accidental burn on thigh region?

Mr. Shah had a D12 compression fracture, spinal cord compression with ASIA type B with neurological level of injury D12 and fracture of the upper end of humerus. After one and half month of ambulation training he could walk with a walker and a KAFO (In a KAFO we have 3 points of support. 1. Thigh band, 2. Knee cuff & 3. Calf band). Apart from the walker and the  KAFO, he required moderate assistance for balance during the dynamic activity of walking and assistance with stepping forward.  He was using moist heat for the pain around the fractured L shoulder. After heating his L shoulder, he kept the hot water bag by the L thigh and due to the lack sensation below D12 (below groin region), he got a significantly large burn on the anterior aspect of the thigh. 

This where we could have had a major setback in his ambulation training. Because of the burn, he couldn't have worn the KAFO. It would have taken 2-4 weeks for the healing to complete. This meant that Mr. Shah would have to stop walking for that period of time. Instead of losing a whole month of rehabilitation, I came up with a plan. I waited for two days for early inflammation to subside.

Then, I used an AFO, a knee cuff, a thigh pad and a calf band to support his leg while walking. I did not tie the thigh band which was over the burnt area - the anterior aspect of thigh. With the AFO, knee cuff and thigh pad we got 3 point support and could manage without thigh band. He had started walking with a KAFO (like device) within 2 days of the burn.

please click here to see photo.
http://gajananbhalerao.wordpress.com/2011/12/06/how-to-do-ambulation-training-with-kafo-in-patient-of-spinal-cord-who-got-complication-with-accidental-burn-on-thigh-region/ 

Don't Just give Push Knee brace as the night splint in FFD in B/L T K R instead make them walk with knee braces to get the dynamic stretch and persistent results

Commonly Push Knee brace as the night splint to correct the Fixed flexion deformity { FFD} in B/L total knee replacement { T K R}. we do knee mobilization and stretching and get the improvement in the extension range but the improvement doesn't last for long time. So commonly push knee braces are used to correct and maintain it.
i get many references of gait training and correction of FFD in TKR. I don't just advice them to use it as night splint or put on when YOU are taking rest but  instead i make them walk with knee braces to get the dynamic stretch during the complex activity of walking. walking with knee brace helps in giving repeated stretch to knee flexion deformity during each stance. and this dynamic stretching happens in the weight bearing position. every time they walk in home they get repetitive stretch and correction of deformity.and this helps in improvement which lasts longer and persistent.

NEURO PHYSIOTHERAPY: What are causes of Fixed Flexion deformity {FFD} in patient is B/L total knee replacement{TKR} and it not always the Hamstrigs tightness.

NEURO PHYSIOTHERAPY: What are causes of Fixed Flexion deformity {FFD} in patient is B/L total knee replacement{TKR} and it not always the Hamstrigs tightness.

What are causes of Fixed Flexion deformity {FFD} in patient is B/L total knee replacement{TKR} and it not always the Hamstrigs tightness.

Post operative Flexion deformity {FFD} in patient is B/L total knee replacement{TKR}is very common. most of the patient land up with 20 -30 degrees of flexion deformity.
what is hte cause of deformity.
1. Hamstring tightness is not always the cause of knee felxion deformity.
2. Post operative they have hug swelling around  the knee. Swelling is the part of recovery it helps in healing. But the swelling causes distension of the joint capsule and reduces the osteokinetic movement of the joint.
3. Stiffness of knee joint: there is severe stiffness because of swelling, immobility, reduced joint play.
4. We may find 10 to 20 degrees of loss of full extension in supine lying examination.But in standing and walking patients shows flexion up 20-40 degrees.
5. Change in the angle of Pull of quadriceps: Swelling causes change the angle pull of quadriceps that also make it to extend the knee completely.
6. Weakness of quadriceps: early stages knee extensors show extension lag, due weakness.
7. Change in Muscle set Point of quadriceps. because of swelling, change in angle of pull and weakness, quadriceps are never able to work in outer range. because of this muscle set point changes and it is not able work in outer range.
8. This cause knee flexion increase in standing & walking {Weight Bearing}  compared to supine or sitting examination.

HOW TO CHOOSE BETWEEN KAFO WITH STATIC ANKLE UNIT & DYNAMIC ANKLE WHILE PRESCRIBING KAFO IN SPINAL CORD INJURY?

While staring Ambulation Training In Spinal Cord Injury we commonly prescribe KAFO for standing and walking. But there is always a dilemma between KAFO with static ankle unit and dynamic ankle while prescribing KAFO in spinal cord injury.

How to decide between with static dynamic ankle unit and dynamic while prescribing KAFO in spinal cord injury?

When patients with spinal cord injury poor control in trunk then use static ankle.

How to check trunk control in SCI?

Make patient sit bed side with hand support if he is able to stabilize himself and hold the trunk upright with or without hand support. That means he is able to manage his trunk stability.

Is it the best way to check trunk control and standing balance with KAFO?

No the best way is give trail standing with KAFO & walker. You should always have a pair of KAFO spare in department to give a trail of standing. In standing if he manages his trunk stability and doesn’t sways a lot. That means he has poor stability in trunk and he won’t able mange the balance in standing with dynamic AFO. So we should give static ankle KAFO.

ON AN AVERAGE RULE

Always give static ankle KAFO in acute rehabilitation; we can convert static into dynamic when he is having good balance while walking.

If still not clear with the idea and not able to decide and you are in the dilemma then give static ankle KAFO

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.

COMPARISION OF BOBATH APPROACH & MOTOR LEARNING PROGRAM

BOBATH APPROACH		MOTOR LEARNING PROGRAMM
Model of motor control
Hierarchical Movement are elicited by sensory input or controlled by central programs. Open loop & closed loop control is used. Feedback & feed-forward influences movements. CNS is hierarchically organized, with higher centers controlling lower centers. Reciprocal innervations are essential for coordinated movement.		Systemic model Personal & environmental systems interact to achieve functional goals. Movement emerges from the interaction of many systems. Systems are dynamical, self-organizing & heterarchical. Movement used for a task is the preferred for achieving a functional goal. Changes in one or more  system can alter behavior.
Theories of motor development
Neuromaturational Changes are due to CNS maturation. Development follows a predictable sequence (e.g. cephalo-caudal, proximal to distal). CNS damage leads to regression to lower levels & more stereotypical behaviors.		Systems Changes due to interaction of multiple systems. Progression varies because person & environmental context are unique. CNS damage leads to attempts to use remaining resources to achieve functional goals. CNS is hierarchically organized. Sensory stimuli inhibit spasticity & abnormal movements & facilitate normal movement & postural responses. Repetition of movement results in positive permanent change in CNS. Recovery from CNC damage follows a predictable sequence. Behavioral changes after CNS damage have a neurophysiological basis.
Assumption of therapeutic approaches
CNS is hierarchically organized. Sensory stimuli inhibit spasticity & abnormal movements & facilitate normal movement & postural responses. Repetition of movement results in positive permanent change in CNS. Recovery from CNC damage follows a predictable sequence. Behavioral changes after CNS damage have a neurophysiological basis.	Personal and environmental systems, including CNS is heterarchically organized. Functional task helps to organize behavior. Occupational performance emerges from the interaction of person & their environment. Experimentation with various strategies lead to optimal solution to motor problems. Recovery is variable because personal characteristics & environmental context are unique. Behavioral changes reflect attempts to compensate and to achieve task performance
Evaluation
Primary focus on performance components Abnormal muscle tone Abnormal reflexes & stereotypical patterns lead to in coordination. Postural control Memory & judgment Stages of recovery or developmental levels. Secondary focus on occupational performance.	Primary focus on role & occupational performance using a client-cantered view. Task analysis to determine performance components & context that limit function & to identify preferred movement patterns for specific tasks in varied contexts. Variables that causes transition to new patterns.  Secondary focus on selected occupational performance components & contexts that limit functions.

MOTOR RELEARNING PROGRAM REFLECTS THROUGH KEY FEATURES

1. It integrates system therapy with motor relearning theory.
2. Central tenet: - the interacting systems within the CNS are organized around essential functional task and the environment in which the task is performed.
3. The key to understanding & promoting control understands of tasks. The essential element within task.
4. This approach also based on the theory that action system within CNS is organized to control of function.
5. It consists of training programme that focuses on specific functional task to engage the systems (musculoskelatal, neuromuscular etc.). Patient instructed to practice those task that present difficulties for them and to practice them in varying environment.
6. Different strategies may be used by individuals and should be allowed if they achieve the desired function outcome. E.g.  – Supine to sit, sit to stand.
7. A variety of cognitive, perceptual motor relearning and biomechanical strategies are used to enhance function.
8. Shift away from a focuses on impairment.
9. A hands on approach is taken to facilitate movement and active participation of patients in learning task to facilitate skills.

10. Active participation of patient in  learning process using cognitive perceptual information processing to decide on the best approach to movement.
11. Patient with severe neurological damage and cognitive impairments would not benefit from this approach.
12. Here they selected several basic functional task such as
a)        Rolling, supine to sit
b)        Balanced sitting & standing
c)        Standing up & sitting down
d)        Walking with or without assertive devices.
e)        Upper limb activities –reach & grasp.
13 .Task performance is analyzed and activities selected for practice.
14.The environment is modified to create as appropriate setting to promote learning and goal directed behaviors.
15.Complex movement are broken down in discrete parts & then practiced as whole.
16. Use motor learning training strategy is component of this approach.
17. Visual guidance of movement and verbal feedback (corrections) are stressed.
18. Manual guidance of movements is limited to only that absolutely essential assist to movement.
19. Key to promoting independent function.
20.Consistency of practice.
21. Appropriate feedback
22. Positive reinforcement
23. Mental stimulation.

Two distinct paradigm shifts in the treatment of neuro rehabilitation, particularly stroke.

The first paradigm shift: Neurotherapeutic approaches

The principle of neurotherapeutic approaches although each neurotherapeutic approach is different from each other; all approaches share some common element. In this study NDT approach is selected because this approach is historically has been the most widely used in stroke rehabilitation.

 The second paradigm shift: functional task oriented training

The second paradigm shift in the treatment of neurological disorders began in 1990s. Therapists have begun to regard neurotherapeutic approaches with less optimism. The dissatisfaction with neurotherapeutic approach is due, in parts, to the fact that retraining normal movement patterns often did not carry over into the performance of functional daily living skills, which was the ultimate goal of rehabilitation. In addition, demand on therapist has been greater to use interventions that have demonstrated effectiveness. The lack of evidence of effectiveness of Bobath approach, has led to the development of novel training regimens based on what has been termed as the task oriented approach.

Note: These notes are taken from Stroke Rehab book.

Principles of Bobath Approach

BOBATH APPROACH

K. Bobath & B. Bobath developed treatment designed to increase normal movement patterns in children with cerebral palsy & adult with acquired hemiplegia. Their treatment focuses on restoring normal movements & eliminating abnormal movements.
 Bobath principles

• The goal of the treatment to retrain normal movement responseson the patient’s hemiplegic side.
• The therapist should avoid activities & exercises that increase abnormal tone to strengthen abnormal movement responses & should use treatment techniques to suppress or eliminate these patterns.
• The therapist should use treatment activities & exercises that encourage or strengthen normal movement patterns in trunk & extremities.
• The therapist should help the patient use existing motor control on the hemiplegic side for functional performance.
• When the patients lacks adequate strength & control of the affected arm & leg for normal functional/occupational performance. The therapist should develop compensations & adaptations that encourages use of the affected side & decrease the development of abnormal movement & asymmetrical postures.

Note: These are some of my notes taken from book; Adult hemiplegia by Bertha Bobath.

How to reduce the walking synergy & circumduction gait?

Walking synergy is cause of difficulty in hip knee flexion and their weakness. in short they r not able to reduce the length of the hemiplegic leg during swing phase, which normally we do.
if we cant reduce the length then increase the length of opposite limb. give a half inch raise on normal leg footwear. this will help in reducing the length and reducing effort then reducing synergy. it ll also helps in increasing speed of walking.
increased speed also improves hip knee flexion. which will help in reducing the synergistic pattern/hemiplegic gait.

WALKING INDEPEDENTLY WITHIN ONE WEEK IN ACUTE STROKE: A Case report

My patient MR. RIMAL PALRECHA with Lt stroke/ Rt hemiplegia had difficulty in voluntary moving the Rt side of body, there was loss of sensation &  hypotonia which lead to reduced bed mobility & inability to sit stand and walk.he  is also suffering from global aphasia. I started treating him from last Tuesday{4/1/11}. on examination he was not able voluntary move the Rt Upper & lower limb.

One week Treatment plan
 I started with training of
1. Rolling on both side with min assistance & bridging ( B/L and unilateral bridging).
2. Supine to sit with min assistance for taking lower limb out of bed and slight push through pelvic to assist him to come to sitting.
3. Sit to stand training: I kept my feet on the affected foot pf patient to not allow to move it during standing. then with min. assistance sit to stand repetitions done for 20 times.
4. Standing with posterior leaflet splint and long-knee brace.
5. Made him walk with this for 10 meters with min to moderate assistance for weight shifts. i had to  assist him to step forward with affected leg. because he did not had control, i had passively lift his leg and shit it forward for stepping.

My objective
My objective was to let him learn first how to take load through the affected leg and start steeping with normal leg. This way i wanted to restore the gait pattern as soon as possible .

What was key factor for development ?
This early introduction of walking in treatment plan created  good background for gait training.
At the end of one week he is able walk independently for 20 meters only with  posterior leaflet splint and no long-knee brace required for stabilization of the knee. He is able to step forward with affected leg. Strength in limb improved to grade 2.
he does not requires my support for walking. i just stand next to him for supervision and hold him when he makes a mistake in stepping and to prevent his fall.

Early standing and walking helped in improving tone, strength and learning of independent walking within one week.
Now i am working on improving the pattern of gait and voluntary control/strength of upper limb and lower limb.

SECOND WEEK TREATMENT PLAN
My objective in this week is to develop his strength in lower limb.
specially concentrating of hip extensors, abductors, and flexors, knee extensors and plantar flexors. I am using all close chain exercises and eccentric lenghening of the muscle this helps in ealry recruitment and loading on motor units. lower limbs and all this antigravity group of muscles work in closed in daily life. so i concentrated on this and functional training.

Exercises program.
1.Briding bilateral -10-20 repitations
2.Unilateral bridging with opposite leg he has to hold in Strait leg raise position in air.
Because of this there is increase loading on the affected leg while briding. to overcome this load.he has put more efforts to raise the pelvis. this helps in recruiting more motor units due to overloading principle. unilateral briding with overloading helps in improving control of pelvic girdle muscles, along with hip extensors,abductors and adductors( work counterbalncing with each other to maintaing leg upright while bridging.) also the platar flexors and intrinsic group of muscle of foot get acivated due to overload and while balancing the load on fett while pelvice is raising up and down during bridging.otherwise activation foo intrinsic muscles is so difficult but with exercise we can do it easily.
Asimple brdging exercise and it variation give us lot of results.
3.hip knee flexion with abduction. This done to get improve control hip knee flexion which will be requred during swing phase of gait for foot clearence.
4. sit to stand with affected behind of normal leg to increas loading through hemiplegia leg.= 30-40 repitations. during hand held together and not allowed use it for support while standing and sitting. this also helps in improving balance during dynamic activity of sit to stand.
5. Squating partial and full 10 -10 repetations.
sqating is again helping in overloading  through affected lower limb, this will help to improve strength of hip extesnors, knee extensors and plantar flexors. this will also help in stretching tight TA tendon and reduce spasticity of plantar flexors.
6. Stair climbing training-stair climbing up- stepping up with normal  leg first then affected leg while down affected leg first then normal leg stepping down.
7. Walking on lelel and uneven/rough ground-outdoor walking. To imrpve the dynamic balance.

DISAGREEMENT ABOUT USE OF VOLUNTARY CONTROL FOR MOTOR ASSESSMENT IN STROKE REHABILITATION

Voluntary control is commonly been used for motor assessment in stroke rehab. It is commonly been taught in all colleges for in neuro assessment.

Original Brunnstrom Grading = Stages of Recovery 

Grade I- no movement or minimum movement possible in short range
Grade II- developing spasticity, partial synergy movement through half range.
Grade III- developed spasticity, full synergy movement through full synergy range.
Grade IV- Out of synergy movement possible.
Grade V- isolated movement possible
Grade VI - normal movement possible.

But there are many problems in practice of use of this in assessment.

Problem 1: There is poor reliability of voluntary control. there is lot of discrepancy between the grading when two assessors evaluate the same time same patients. some time this poor reliability play a major role discrepancy between the examiner and the student. now you tell if the student make some mistake during grading using this scale. Is it the scale is at fault or the student? GOD please help the poor student.

Problem 2:Disagreement about the many scaling methods.
Proposed scaling method are: some PT's use six point scale 1-6. But many people use seven point scale 0-6. zero as no movement and grade 1 as min voluntary contraction. this way it will be a seven point scale 0-1-2-3-4-5-6. where as in the original Brunnstrom grading it was only 1-6. now the question arise that - no movement and  min voluntary contraction should be graded as zero 0 & 1or 1.


Problem 3: Separate voluntary cotrol for each joint (shoulder/ elbow/ wrist/hip/ knee/ ankle } and and each movement of flexion, extension, abduction or so on.
Can anyone tell me, in which book where this type of assessment methods given.? So that we can use this as reference. As per my knowledge no book has given this type of assessment methods. It is just a method to add to confusion to  already complicated scale.

Problem 4: This commonly taught and practice in education system with different ways, whichever is convenient to use. there is no standardization. for every new argument about scale there is new answer  and origin of new method of scaling.

Problem  5: There are many good valid and reliable scales are available but there use is less common than voluntary control scaling. Other  scale STREAM format Motor assessment scale, Fugl Mayer scale which are reliable, valid, and given the details of scaling

Need of neuro physiotherapist for patients with neurological disorders

I feel there is a hug need for neuro physiotherapists. There are so many people are sufferening from stroke/hemiplegia, head injury, spinal cord injury who requirs specialized therapy by people who are trained in the neuro rehabilitation.