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TREATMENT PHYSIOTHERAPY IN THE FIRST STAGE (FLACCID MAINLY):
Turning over from supine to side lying .
One of first activities the physiotherapist should work for in treatment is that of turning over to either side. The patient should not always remain in the supine position but should soon learn to use his trunk; i.e. his shoulder girdle and pelvis to turn over and lie on his side for some part of the day.
If patient rolls over and lies on the sound side, with the affected arm uppermost, the shoulder and arm should be moved well forward, the elbow should be extended, and the affected leg lie in a natural position of semi-flexion.If patient rolls over and lies on the affected side, the shoulder of that side should again, be placed forward with the elbow extended and in supination.
This position helps to prevent shoulder retraction and the development of flexor spasticity with pronation of the affected arm.Patients clasps hands, he then raises arms. In this shoulder girdle is moved forward and upwards. Patient’s arms are then moved, with clasped hands to chest. With clasped hands, patient turns towards sound side keeping shoulder well forward.
Lying down from sitting
The physiotherapist holds affected hand of the patient, his arm externally rotated and extended diagonally forward at shoulder height, while the patient slowly lies down, using his sound arm for support. In this way, physiotherapist will prevent retraction of the shoulder and flexion of the affected arm. The patient then lifts the sound leg on the bed. If at all possible, he should then bend the affected leg at the knee and move it into the bed, the nurse giving a little help by lifting from under the knee.
Sitting and standing up
A foam rubber mat should be placed in front of the bed for standing. The therapist never be on patient’s sound side when he sits, stands or walks, since he can use his sound side. If he takes weight on his affected side, the patient will gradually overcome his fear of falling.
We all know about it. In simple words, we can say damage to the brain from interruption of its blood supply. It’s also called CVA: cerebro vascularaccident. Now just have a simple look or idea about the patient’s structure means his look so that he can recognize about that. Firstly side of the face drops or feels numb with speech difficulties as face involves in it, then muscles weakness on one side of the body.
There are three types of stroke:
1 Ischemic strokes
2 Hemorrhagic strokes
3 Transient ischemic attacks (TIAs)
BUT there is also something that we should know:-
There are two types of patients, first those patients with both flexor and extensor spasticity; but predominant extensor hyper tonus of the leg, i.e.excessive co-contraction.
They can stand and take some weight for a moment.Other patients with more moderate degrees of spasticity and little co-contraction can walk and move the weight free leg.Both types of patients have balance problem, the first because of lack of mobility and the other due to lack of stability.
NOTE: If left brain involved then right side affected and if right brain involved then left side.
TREATMENT FOR STROKE
Before start treatment one should know about the following things.
Check the muscle first either it’s flaccid or spastic.
Sensory part involvement is there or not.
Check the reflexes
Bo bath: This is based in normal movement or Neuro -development approach.The main aim is to prevent abnormal movement and adverse plastic adaptations and to facilitate normal movement and subsequent plastic changes.
Brunstorn: He makes use of abnormal synergies and incorporate them into functional activities.
Motor relearning program: This training of motor control is based on an understanding of kinematics and kinetics of normal movement, motor control process and motor learning.
Proprioceptive neuromuscular facilitation (PNF): To maximize sensory stimuli on the pool of AHC in order to stimulate purposeful muscle contraction.
Roods: This was mainly done to achieve purposeful muscular contraction by stimulating the skin through facilitating strokes on the skin. The combination of treatment used differs from patient to patient.
TREATMENT FOR CONTROL OF MOVEMENTS OF THE ARM:
The patient has great difficulty in lifting and holding his arm up against gravity ,because flexor spasticity of the trunk and shoulder girdle with shoulder girdle with pressure downwards prevents the action of the extensors, i.e. serratus anterior, deltoid and supraspinatus.
Inhibition of spasticity can be achieved more easily in supine, as already described in the first stage of treatment and this has to be continued in preparation for working in the upright posture. It is easily obtained in standing, rather than in sitting,because in standing extension of the hips facilitates lifting of the arm whereas, in sitting, flexion of the hips and trunk make inhibition of flexor spasticity more difficult.In order to make lifting of the arm possible, the patient must first be able to hold it at various stages when lowering it.
He should extend his elbow and keep it extended all the way down. But extension alone is not sufficient.The arm should be in external rotation and supination, as internal rotation and pronation are part of the flexor pattern which counteracts lifting and holding the arm up. Control for holding the arm up at the shoulder is easier when it is held sideways rather than forward and down. T
his is because extension with external rotation and supination can be maintained more easily sideways than forward.In supine, standing and sitting, it is easier for the patient to hold his arm against gravity than to lift it up.
If he can control the weight of his arm all the way downward, he can also learn to lift it up from any downward point at which he is able to hold it. If the arm pulls down at any stage of the downward movement, the therapist will feel downward pressure against her support and the movement should then immediately be reversed upward, either by the therapist or better if possible by the patient. He soon learns to recognize the moment when flexor spasticity occurs and his elbow tends to bend.
To begin with the therapist holds the patient’s hand with wrist and fingers extended, the thumb abducted. The patient extends his elbow, pushing against the therapist’s hand. She would be able to use some intermittent pressure to stimulate active extension.
When he can hold his elbow in full extension, she moves his hand slowly sideways and down, but only as long as he is able to keep his elbow extended. He is then asked to move his arm up again. Gradually, the whole range of movement sideways for full horizontal abduction is performed. The movement is then done diagonally forward, as long as external rotation can be maintained.
As a progression, the therapist holds the patient’s fingers but only lightly to prevent the occurrence of flexion until she is able to take he hand away at various points of the downward movement and the patient is able to control his arm at each stage. This is called placing.If the patient’s arm is more flaccid than spastic, contraction of the deltoid, for holding the arm up in horizontal abduction, can be facilitated by suddenly and without warning dropping the arm, but letting it fall only a little way down, then moving it up again. Letting it fall may produce a protective holding reaction through sudden stretch in the inner range of the deltoid and supraspinatus.
The patient can then use this contraction immediately, i.e. before its effect has subsided, for lifting his arm up again.This manoeuvre will not work, however, if there is any flexor spasticity. Another way of stimulating active extension of the flaccid arm is a technique which we call (pull- push). With the patient’s hand held with wrist and fingers extended, his arm is raised sideways to the horizontal and a quick pull followed by a push against his extended arm, is given through his hand.
This stimulates mobile extension of the elbow and a holding action at the shoulder. The patient now feels that he can extend his arm without it stiffening, and through the pull, followed quickly by pushing against the extended arm, the therapist inhibits flexor spasticity. This combination of inhibition and stimulation is very useful and should be done with the patient’s arms in any direction, sideways, forward and diagonally, and also gradually downwards.
When sufficient activation has been obtained at shoulder and elbow,the therapist lets go of the patient’s hand and he should hold his arm up unaided. Inhibition of flexor spasticity has to be done during and if necessary, in between all the placing maneuvers described above, i.e. when the patient’s arm becomes heavy and uncontrolled, or when a pull downwards is noticed by the therapist.
The patient may now be able to lift and hold his arm at the shoulder,provided he keeps his elbow extended. The moment he is asked to bend his elbow so that he can bring his hand to his body or face, the whole pattern of flexion, pronation and downward pressure of the side flexors of his trunk and retraction of his shoulder girdle may come into play and he can no longer hold his arm up.
For functional use, i.e. for feeding, dressing and other activities, it is essential that he should be enabled to bend and supinate his elbow and open his hand to grasp, while holding and stabilizing his raised arm at the shoulder. Treatment therefore, should be advanced towards obtaining independent movements of the elbow without letting the arm fall.
EXERCISES IN PRONE LYING AND KNEELING
He is asked to lift sound arm so that all pressure comes to the affected side. Poor balance and arm support on left affected side. Rocking backwards and forward , balancing on affected knee.
Weight is on affected side but note slight retraction on affected side.
EXERCISES IN SITTING
Weight bearing on the affected upper limb:
The therapist sits behind the patient and maintains the arm in slight abduction and extension with elbow extension. The patient should be encouraged to weight bear with the arm in this position. As the patient improves the support given by the therapist should be gradually reduced.Facilitating weight transmission through affected side.