early rehabilitation of the trunk and LL and UL Flashcards
observations in sitting with patient with hemiplegia
they might lean toward their unaffected side and compensate with this side,
what do we need to do-trunk?
realign trunk- i.e. strengthen the affected side and improve the QOM,
trunk realignment- therapist
sit behind patient with cushion, ways to reduce fixation= take support of them and position hand on leg with palm upwards (stop gripping) and reduce feet fixing= BOS unstable, trunk lateral shift to stretch (obliques)= stabilize around shoulders or rib cage, extension of trunk, anterior/posterior pelvic tilt
trunk realignment- test balance
can do static (lifting arms and legs) or dynamic (reaching- 2 therapist- one support upper body one support shoulder) to challenge BOS, can use gym ball to stretch- lean on ball, can sit on wobble bored- higher level- progression
observation of SCI
spinal cord stability sitting- patient hyperextended elbows backwards and forwards to stabilize (tenodesis), mirror in front= visual feedback, close eyes- challenge vestibular system, sensory feedback from hands, ensure patient doesn’t fall forward
transfer with hemiplegic
practice with transfer board, rotunda
why is standing a good position for physio
high COG/small BOS, increased weight bearing/ strength and motor recruitment, psychological benefits, visual stimulation, increased bone density, decreased risk of secondary MSK complications, cardiovascular benefits, respiratory benefits, relieve pressure, bladder/bowel sensation
sit to stand with hemiplegic patient
sit on chair lower than bed, wedge leg in between leg, positioned to side to allow space, then stand (place hands on hips), make sure something is there to hold when standing, ensure equal weight bearing, wants to active hip/knee extension by tapping when stepping, first practice weight transfer then step (may need to move damaged leg)
potential problems with standing with hemiplegic patient
BP/HR, autonomic dysreflexia, bowel/bladder, respiratory dysfunction, colour/sweating
advantages of mechanical standing aids
conform to mannual handling guidelines, allow early rehab of heavy patients, allow rehab of very disabled patients, allows for grading of movement, require fewer staff
restrictions of mechanical standing aids
activity level is restricted by equipment, not normal sensation of standing, reduced feedback to therapist re activity
example of mechanical standing age
tilt table, oswestry standing frame
UL observations- from behind
levels of shoulders (UF traps), spine to medial border of scapula, spine to inferior angle of scapula, position of inferior angle scapula, scapula to humerus, skin folds
UL observations- from the front
position of head/ trunk/ elbow/ wrist and hand, suprascapular fossa should be equal, arms flexed forward to 90°- dimples above deltoid
Assessment- AROM and PROM
quality of movement (2:1 scapulo-humeral rhythm, associated reactions, pain, compensations/abnormal movement patterns)
PROM- range/ feel (tone), ? pain)
Assessment- other
strength (low tone=isometric), coordination- FTN and HTS (dysdiachokinesis), sensation, function- dressing/ grooming/ drinking/ writing/ grips
what does stability of the GHJ depend on
direction of glenoid fossa, glenoid labrum, capsule (superior part), rotator cuff
inferior subluxation
scapula looses stability on thorax- depression and MR, humerus in relative abduction, joint unprotected by stability of capsule and supraspinatus
anterior and superior subluxations
anterior- due to tight pecs and lat dorsi, superior- due to tight supraspinatus or deltoid
subluxation and pain
can result in pain for people with hemiplegia due to-
soft tissue overstretching- to muscle imbalance, alteration of joint biomechanics, soft tissue injury, traction to blood vessels= ischaemic pain, impingement, altered sensitivity, sympathetic changes- shoulder- hand syndrome
hemiplegic shoulder pain
limits function, limits therapy, poor recovery of UL function, longer hospital stay, poor discharge home rates
early treatment options for stroke and TBI= care of shoulder and hand Edema
shoulder= education/ positioning/ supportive devices
hand edema= passive/ AROM, measure oedema- prevent CRPS/ CPM hand, FES hand
early treatment options for stroke and TBI= whole arm and splints
whole arm= strengthening/ mirror box/ mental practice/ sensory retraining/ compensatory technique/ spasticity/ FES
splints
care of shoulder
importance of not pulling on shoulder or arm when moving in bed, transfers etc.
educating familt and carers about care of shoulder, shoulder subluxation subcuffs
whole arm strengthening
strengthening- simple isometric techniques such a holding/ following/ placing/ combine with taping,
strengthening and ROM in sitting
approximate humerus (slight lift and LR if tight pecs), may get patient to rest hand on knee and rock side to side, then progress to sliding hands along thigh (tap triceps), may facilitate with sensory feedback
strengthening and ROM in lying
lye in supine- stabilizes scap, slight approximation to 90° flex, add slight protraction, rest hand on head- tap triceps to extend arm (functional), holding (tell patient not to let you move arm)
things to know with early UL rehab
alignment, know normal, early strengthening, facilitate
what is functional electrical stimulation (FES)
the process of pairing stimulation simultaneously or intermittently with a functional task
FES uses
strengthen and/or maintain muscle bulk, facilitating voluntary muscle contraction, gaining/maintaining ROM, increase sensory awareness, reducing spasticity, as an orthotic substitute to produce functional movement
electrical stimulation of muscle
damage to nervous system produces denervation of muscle resulting in weakness or paralysis
the lack of neural innervation renders muscle unable to produce the voluntary forces needed to create joint movement
clinical application of FES
foot drop (MS and CVA), hemiplegic shoulder pain, paraplegia (standing/ cycling/ walking), exercising= decreased spasticity and adhesions, increased circulation main use (foot drop and hemiplegic pain)
FES- quality of human movement
muscle contraction- less efficient than human movement. it induces excessive neuromuscular fatigue. It should be used with other traditional therapies
contraindications and precautions
patients who do not comprehend the physio instructions, electrode placement not- on trunk/pelvis/uterus during pregnancy, over eyes, epiphyseal regions of children, patients with pacemaker, skin allergies, dermatological conditions, area of tumour
Contraindications
abnormal skin sensation, current/recent bleeding, compromised circulation, application over neck, area of active TB, area of devitalised skin, patients with epilepsy
applications of microstim
turn to mdoe 5, attach lead to electrode, black electrode over muscle proximally, red over motor point, attach lead to stimulator, turn on and slow, increase until a contraction is elicited, move red electrode to locate optimal contraction, turn off and change to mode 6
sensory stimulation
textures- different clothes, temperature- cold (cutlery) or hot (hot drink), positions
what is mental practice
the process of imagining and rehearsing the performance of a skill with no related overt actions. Used for stroke patients, phantom pain, CRPS, arthritis and chronic pain after surgery. E.g. imagine picking up class
what is mirror therapy
patients sits with the affected arm behind the mirror. Focuses on the reflection and imagines it is the affected limb. Recommended 10 mins a day, may cause emotional response, dizziness or nausea
mirror therapy- without object
unilateral movement on the good arm only (flex, ext, pro and supinate, lumbricals), bilateral movement, guiding of the affected arm by the therapist, guiding of both arms by therapist
mirror therapy- activities with object
unilateral movement of the good arm with object, bilateral movements with an object in the non-affected hand, bilateral movements while imaging objects in hand
how does mirror therapy work
it increases cortical and spinal motor excitability, possibly through the effect on the mirror neuron system- these are responsive for the ability to differentiate between left and right side- activated during MT. this system is thought to use the observation of movement to stimulate the motor processes which would be involved in that movement. brain prioritises visual feedback
