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

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.