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.