Hemiplegia

[Ankit]

Hello!
I just need an advise for a chronic Hemi case
She is having Hemi plegia since 3 years
Though she can walk with stick but with circumductory gait
hip adductors are laxed and invertors are spastic
and in upper extremity there is spasticity in flexors and extensors are loose
so plz advise me what should i do with her so then c can live her life with more comfortability

Any advise most wel come

[ratri]

hi anikit,
try normalizin the tone by facilitation of low tone,n inhibitin high tone.
and normalization of muscles tone involves weight bearin on the affected side(joint compression),scapular protraction,trunk rotation,strechin of spastic muscle,n appropriate positoning can be given.

[Ankit]

Oh! Hi
Ratri
Thankx for your kind reply
other advises are good but is it fair to go with stretching of spastic muscles as it is a chronic hemi case. and what is the other thing is i m giving wt bearing on lower extremity but the response is very low.

[ratri]

hi ankit, oh instead of strechin you can use roods (slow strokin)n i think u can also give prolonged iceing,response may be slow cos he must have not taken continious treament in that period of 3yrs ,wat do u think?

[Ankit]

Oh ya
infact i have joined her just b4 a month
so i m trying to get as much as i can for her
she is having right hemi so speech problem is also there
is there any special treatment for aphasia???

[Gawaine]

wow dude, there's a lot you need to consider here... are you treating her for hemiplegia? has she had treatment before? at 3 years, she may not make huge gains, though if she hasn't had good therapy and has been getting some return lately you may be able to hone in on that and improve her function and quality of life...

you should start with solid observation-- and by telling us more about the patient... age, history, other demographics--- then what about her functional abilities?? how are her transfers from various surfaces? how is it done? is it within a normal range or abnormal?

asking how to treat hemiplegia is a big question... every stroke patient is different... but here are basic guidelines:

1) do functional activities--- picking up balls or just standing or just bearing weight through the arms is NOT going to retrain the brain
2) fix whatever goes wrong -- if you ask her to raise her arm in shoulder flexion and you get a spastic, synnergy pattern, then you should help guide her into the correct pattern
3) ask for a motion-- if it doesn't happen, demonstrate it, facilitate it (as lightly as possible), and help the motion happen... if she can't get there, check passively for mobility... does something need to be stretched or mobilized?? once you get the range, go back and facilitate again... if it can be facilitated, ask for it without using your hands...
4) grade your activity -- if she can slide her arm into shoulder flexion on a level table, then increase the difficulty just a little bit-- add some resistance, increase the angle, or otherwise make it a bit harder...
5) stretch CAREFULLY -- the hemi hand and the hemi shoulder are generally painful and VERY delicate due to subluxation, poor alignment, atrophy, and spasticity... when stretching the internal rotators of the shoulder (and i'm SURE they'll be tight), hold the distal portion (the upper arm) solid and have the patient move their body away... this can stretch the pects and deltoids-- the subscap is a difficult one to stretch but can be done with some training... the hand should be opened in this order (if it's held in a tight fist) --- wrist flexed, extend the thumb, spread the metacarpals, extend the IP's, extend the MCP's, then extend the wrist... you should maintain the new range with splints... if she has active movement (especially extension), progress to various functional activities...

PT's take LONG courses on hemiplegia rehab... there are bobath/NDT/neuro-IFRAH courses, PNF courses, and other rood/brummsfeld (sp?) courses you can take... good luck... if you have more specific questions, i could try to help you out...


patrick, MPT

[Ankit]

Hey Thank you very much for this reply....
If i could have ur email id then i will show u that video of patient.
Especially there is not movement in upper extremity(expecially at shoulder) but during icing on extensor on forearm and hand i can get fingers extension.
NO EXTRA MOVEMENT IN UPPER LIMB.

And for lower limb i m giving her wt bearing and SLR and passive hip knee flexion.

she can do hip flexion till 30 degree in supine position and nowadays i m trying to learn her to kick the ball.

But i m very confused about the upper limb. Can i go for any electric modality like stimulator or something.

Awaiting for reply..

Ank

[ratri]

hi ankit, you said upper limb is spastic so no electric modality can be applied,as there is alredy increase in tone............(cos of tremendeous motor firin)

[Ankit]

Hey Sorry to interrupt u again but can i go for stimulation of extensor as flexors are spastic and when i icing on extensors the fingers come totaly extension.
so it would be better to go for stimulation????????????????????
if u give me ur id i can send u her video if u dont mind.....

[ratri]

hi,ya if extensors are hypotonic then u can give stimulation ........hav u tried givin prolonged icin to flexors as it ill help in reducin the tone......

[Ankit]

Yeap i have tried prolonged icing but as i told u its a chronic case to it takes time to reduce the tone...
if any other for upper extremity plz let me know thank u


Ank Soni

[Gawaine]

i watched that video........ it looks like a betamax tape of a 3rd world country...
my number ONE suggestion would be to get her an ARTICULATING ankle-foot-orthotic... go from there...

has she never had a neuro-trained physical therapist treat her? she definitely needs a lot of work or she'll end up with more contractures, pain, and orthopedic injuries...
you should also GENTLY stretch the hand open with the sequence i mentioned above (practice it on a colleague or friend) and then get her into a splint... i recommend saebo splints if you can get them in your country... otherwise any SOFT splint will do...
you will need to develop control of the hemi lower extremity... do things in functional activities........

there's just so much to teach regarding treating a hemi patient... it's like asking how to fix a car... there are so many things that can go wrong and so many things you can make worse so quickly...

if you're planning on treating more patients from this population, i suggest advanced courses in NDT, PNF, and/or neuro-IFRAH ...

good luck!!


patrick, MPT

[Ankit]

thanks sir for kind reply

but dont leave this type like hanging me

i m giving her one splint of hand that one is normal but hard

so is it better to go wid it

plz suggest me

thanking u

Ank

[Gawaine]

i can't stress how important it is to start with the sequence of hand-opening mentioned above... from there you want to do some mobilization of the joints, some stretching of the finger and wrist flexors, and possibly some active range and functional tasks is appropriate...
when putting someone in a splint, keep in mind that their spasticity will return and possibly increase due to the resistance... !!!!! basic PNF concept--- you apply resistance, a muscle increases its contraction... there are EMG studies supporting this concept... so a soft splint, preferably one that gives a little when the hand flexes, is best...
take a look at the saebo stretch splint:

http://saebo.com/saebostretch.html

look at the pictures down the page... this is what happens when a hard splint is left on for quite some time and the patient tries to transfer and do other things that cause the spasticity to increase... so consider that--- you put the splint on, now see what the hand does when the patient transfers... is your splint going to do more harm than good?
i'm not here to promote any specific splint... i just know that the saebo one is a good product... if your patient has little increase in spasticity with transfers and gait, then a hard one may be appropriate... just consider all your options and all the consequences...

[surraya]

im just a 2nd yr student!! my question is what exactly happens in the brain to cause the high tone in individuals suffering frrom hemiplegia.thanks for your time. surraya

[Gawaine]

oh, well, let me just give you a little quick neuro physiology lesson.....


when spasticity has set in, it means that the squirrels that were previously turning the wheels in the brain have become tired and were easily taken over by the aliens that infiltrate our cerebrums while we sleep... that and the microwaves from the radio towers squeeze everything really really tight...



patrick, MD