Problems and treatments

Question 1

Hypotonia UL

Answer 1

Active assisted proximal shoulder strength exercise with hold
HCSP at central key points
physio infront practicing random practice and targets

Justification:
- Proximal strengthening due to weakness form lack of stimulation, increase stimulation and stability (avoid hemiplegic shoulder)
- strengthening in midrange
- Bi-manual = both limbs strengthening at the same time, increases sensory feedback between the two hemispheres to promote movement in weak arm
- Carr and Shep = Target/ goal orientated with cognitive/ visual cues, patient lead, functional movement (reaching, sitting), normal movement for patient, active assisted but using affected side,
- Central key points = Bobath

Question 2

Hypotonia LL

Answer 2

Supine to crook lying, glide sheet hip flexion exercise,
Towel under foot, bring heel to bottom
Add small hold/ leg raise for progression

Justification:
- proximal strengthening, due to weakness from lack of stimulation and stability. (then work to distally)
- increase proprioception through towel, and reduce friction from bed
- Carr and shep = affected side, patient lead and working up to functional movement with transfers or walking as movement of all LL joints

Question 3

Hypertonia UL

Answer 3

in sitting, physio on stool. Hand shake stretch exercise, massage out into extension and external rotation and hold, then relax and repeat.
pillow under to de-weight the arm and reduce strain though joint (can increase tone)

Would later strengthen and splint with 24hr positioning. Load through joint eg: wall press ups or PNF

Justification:
- stretching little and often,
- avoids contractors and pain in patient, allowing then to do more functional things if stiffness (flexion) reduced
- Slight bobath concept as HCSW keeping good posture and point of exercise is to regain movement through therapist lead exercise

Question 4

Hypertonia LL

Answer 4

Position limbs, remove adduction and pointed foot, then stretch Plantar flexors , then load through into dorsiflexion in sitting on your knee, hold then again
HCSW in behind holding CKP
Then ask patient to reach forward to touch over left/ right shoulder (target) to increase stretch

Then strengthen antagonists (dorsiflexors) and load through joint e.g. TheraBand wrap dorsiflexion raises and hip abductors (clams)

Justification:
- stretching little and often to avoid contractures and pain and promote normal limb positing to allow walking in future.
- then strengthen to inhibit high tone and remain in dorsiflexion// hip abduction

Question 5

Decreased postural control/trunk control

Answer 5

In sitting, bring pt to midline (HOLD)
HCSW in behind at CKPs
physio in front
add wobble cushion underneath
lift one leg for progression

Then in lying 90 degree bent knee hold/ dead bugs

justification:
- strengthen trunk muscles to better postural
- add pillow for proprioceptive feedback and reduced balance = intense
- bring to midline for good posture (body function and functional movement to transfere into other tasks)

Question 6

Decreased sitting Balance

Answer 6

in sitting, HCSW holding CKP with pillow for pt to lean back into
towel underneath weakside
physio infront on stool, can deweight arms with them on shoulders if needed
pelvic tilts (posterior, neutral, anterior and lateral)
Ask patient to hold in middle for 10secs then relax back into pillow
Reach out of BOS at challenge

Justification
- balance exercise so little and often
- strengthening trunk and postural control to improve balance
- Bobath as high facilitation to promote motor and sensory feedback, quality movement focused on good posture and activation of trunk muscles,
Adding in target = task specific and functional

Question 7

Decreased standing Balance

Answer 7

Get pt sit to stand with support, HCSW raises plinth and shuffle to hold on with both hands out infront (can use for support and de-weighting of arms)
Lateral weight transferes from on leg to other facilitated with worker on each side
Then remove support and see if they can remain balances

Justification:
- Balance exercise so little and often
- strengthening core with load though joints and feet for proprioception
- functional and highly transferable
- lateral weight transferes like walking and reduces BOS
- make movements dynamic to improve balance, outdoors, in their environment and on different surfaces

Question 8

Fine Motor control

Answer 8

In sitting HCSW in behind, retracting and depressing shoulder with CKPs held
physio in beside arm working, facilitate pinching task
then pt does by themselves (physio adds in random practice)
Then
Reach and grasp exercise with cone targets and towel underneath to reduce friction, facilitate reach, then faciliate only graps
Grasp and move, then grasp and stack on different colours

Justification:
- strengthening dexterity and distal muscles of the hand
- Bobath = quality movement, no compensation, facilitation to encourage sensory and motor feedback to encourage muscle activation, good posture all way through with HCSW at shoulder, targets and task specific
- functional with tasks and sitting, reaching and stacking
- multimodal exercise with cognitive exercises to increase salience and intensity
- random practice = autonomic learning

Question 9

Foot Drop

Answer 9

in sitting, stretch out plantar flexors with forearm, HCSW behind
Put foot on knee and load through pt knee to increase dorsiflexion (HOLD)
Ask pt to reach forward over shoulder to target to increase stretch and angle of dorsiflexion and reduce oedema by encouraging pump

Then strengthen dorsiflexion to encourage this when walking. Heel to toe rocking and theraband dorsiflexion strength

Justification:
- stretching little and often then strengthening to remain in neural position and encourage ability to dorsiflex during walking (increase ROM)
- very part practice to allow further rehabilitation down the line to improve gait