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Low level Paraplegia

Definition:

It is paralysis or weakness of both lower-limbs due to bilateral pyramidal tract lesion in the spinal cord(T12 to L4).

Causes of Spinal Paraplegia:

I- Focal causes:

A.

Compression:

1.

Vertebral:

  • - Fracture or fracture-dislocation of the vertebra, Disc prolapse and spondylosis,

Neoplastic diseases: Primary or metastatic and deformity of the vertebral column as

kyphoscoliosis.

  • 2. Meningeal (extramedullary):

It may be extradural, .dural or intradural.

  • 3. Cord (intramedullary): Syringomyelia.

  • B. Inflammatory: Transverse myelitis - Myelomeningitis .

  • C. Vascular: Anterior spinal artery occlusion.

II. Systemic causes:

When a systemic disease affects the pyramidal tracts, either alone or with other tracts, paraplegia will result. It may be heridofamilial, symptomatic or idiopathic.

III. Disseminated cause: Disseminated Sclerosis (D.S.)

Clinical Picture of Focal Paraplegia

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  • A. At the level of the lesion:

    • 1. Vertebral manifestations: Only present if the cause is vertebral.

  • - Localized pain or tenderness.

- Localized deformity or swelling.

  • 2. Radicular manifestations: Only present in extra-medullary causes.

  • a) Posterior root affection:

  • - Early pain in the back referred to the distribution of the affected root.

  • - Later, there is hypoesthesia or anesthesia in the dermatome supplied by the affected root.

    • b) Anterior root affection: localized L.M.N. weakness in the muscles supplied by the

affected root.

B. Below the level of the lesion: (cord manifestations):

  • 1. Motor Manifestations: They depend on whether the cause of the lesion is acute or

gradual.

  • a) If the cause is acute (inflammation, vascular or traumatic), the paraplegia passes

through 2 stages:

• Stage of flaccidity due to neuronal shock:

there is sudden paralysis of the lower limbs, associated with complete loss of tone

and absence of reflexes.

• Stage of spasticity due to recovery from the neuronal shock:

On recovery from the shock stage, the full picture of U.M.N.L. will be estab-lished

including: hypertonia, hyper-reflexia, positive Babinski sign & may be clonus.

  • b) If the cause is gradual (e.g. neoplastic): The shock stage is absent and there will

be gradual progressive weakness of LL with hypertonia and hyper-reflexia. N.B: Piere Marie Foix test is done by firm passive plantar flexing of the toes and foot.

This will result in spontaneous "withdrawal reflex" i.e. spontaneous flexion of the hip, knee and dorsiflexion of the ankle if the paraplegia is passing from extension to flexion.

 

Paraplegia in extension

Paraplegia in flexion

  • 1. Pyramidal lesion

Cause

 

Pyramidal and extrapyramidal

  • 2. Hypertonia

More in extensors

More in flexors

  • 3. Extended

Position of L.L.

 

Flexed

  • 4. Exaggerated

Deep reflexes

 

Less exaggerated

  • 5. Present

Clonus

 

Absent

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2. Sensory Manifestations:

  • a) If the cause of the lesion is extramedullary, encroachment on the ascending tracts

at the site of lesion results in sensory level below which, all types of sensations are diminished. There is early loss of sensation in the saddle area (S 3, 4, 5), as the sacral fibres lie in the outermost part of the spinothalamic tracts in the cord. b) If the cause of the lesion is intramedullary, there will be a jacket sensory loss (hyposthetic area with normal sensations above and below it). The sensory loss is of a dissociated nature i.e. pain and temperature sensations are lost but touch and

deep sensations are preserved; The sensations over the saddle area are preserved (sacral spare), as the sacral fibers lie far from the midline lesion.

3. Sphincteric Manifestations:

a. In acute lesions: There is retention of urine in the

shock stage, followed by precipitancy of micturition. b. In gradual lesions: There is precipitancy of micturi¬tion which may terminate in automatic bladder when complete transaction of the cord occurs. * These changes start late in extramedullary lesions and early in intramedullary

lesions as the pyramidal fibres controlling the blad¬der centre lie medially in the cord.

4.Sexual dysfunction.

5.Impaired sympathetic outflow. Classification of spinal cord injury:

A)Complete injuries:

Anatomically rare but clinically may be found .It means that no sensory or motor

function in the lowest sacral segments (S4-S5).

B)Incomplete injuries:

There are residual motor and sensory function below the neurological level including

sensory or motor functionat S4,S5. C)Zones of partial preservation:

Appears when an individual has motor and/or sensory function below the neurological level but doesn’t have function at S4and 5 . Secondary complicatios of SCI:

1)Spinal instability. 2)osteoporosis and renal calculi . 3)Heterotopic ossification.

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4)Respiratory complications. 5)Pressure sores. 6)Autonomic dysreflexia(hyperreflexia) 7)Orthostatic hypotension.

Relationship of spinal segments to vertebrae

Cervical ……….add 1 T1-T6 vertebrae…….add 2 T7-T9 vertebrae …………add 3 T10 vertebrae……….L1-L2 segments . T11 vertebra …………L3,L4 sgments.

T12 vertebra………

L5

segment.

L1 vertebra…………

All

sacral and coccygeal segments.

Levels of paraplegia:

1)High level:from T1 to T7 segment. Abdominal muscles are severly affected. 2)Mid level:from T8 to T11 segment. Abdominal muscles are partially affected. 3)Low kevel:from T12 to L4 segment. Abdominal muscles are nearly free.

Physiotherapeutical assessment for traumatic spinal cord injury:

A)History 1)Personal history:

Age: occurs mainly at young age. Sex:occurs In males more than females. 2)Present history:

Onset:sudden Course:mainly regressive. 3)Past history:

Trauma

B)Examination:

1)Mental examination:

Mood and affect changes may occur.

2)Motor examination and sensory examination:

Designation of lesion level:

-Neurological level:

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The most caudal level of the spinal cord with intact motor and sensory functions bilaterally. -Motor level:

The most caudal level of the spinal cord with intact motor function bilaterally. -sensory level:

The most caudal level of the spinal cord with intact sensory function bilaterally.

The most caudal level of the spinal cord with intact motor and sensory functions bilaterally. -Motor

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3)Respiratory assessment

Less important in low level paraplegia asrespiratory muscles are free.

Chest expansion Breathing Pattern Cough Vital capacity 4)Skin Examination:

Regular skin inspection should be done and teached to the patient and the family.

3)Respiratory assessment Less important in low level paraplegia asrespiratory muscles are free. Chest expansion Breathing Pattern

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5)ADL Examination: It must be done to determine the functional ability of the patient with cautious

5)ADL Examination:It must be done to determine the functional ability of the patient with cautious so as not to stress on the fracture site.

Physical therapy treatment:

Icu phase

  • - Respiratory management

  • - Posioning

  • - Passive range of motion exercises

  • - turning respiratory management:

5)ADL Examination: It must be done to determine the functional ability of the patient with cautious

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Breathing Exercises

Breathing Exercises Incentive Spirometry Postural Drainage 9

Incentive Spirometry Postural Drainage

Breathing Exercises Incentive Spirometry Postural Drainage 9
Breathing Exercises Incentive Spirometry Postural Drainage 9

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FIGURE 25.37 Patient lies prone with a pillow under the abdomen to flatten the back. Percussion
FIGURE 25.37 Patient lies prone with a pillow under the abdomen to flatten the back. Percussion

FIGURE 25.37 Patient lies prone with a pillow under the abdomen to flatten the back. Percussion is applied bilaterally, directly below the scapulae.

Postural drainage with percussion and vibration may be nec- essary to aid in clearing secretions. Many facilities employ respiratory therapists who are responsible for these activi-

ties. However, the PT or PTA may be the health care provider responsible for the patient's bronchial hygiene (removal of secretions).

Assisted Cough Techniques

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Several methods are available to assist patients with the abil- 13

Several methods are available to assist patients with the abil-

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ity to cough. Depending on the patient's medical status,

these techniques can be initiated in the acute care setting or

during the early phases of rehabilitation.

Technique 1. The patient inhales two or three times and, on

the second or third inhalation, attempts to cough. Intrathoracic pressure is allowed to increase to allow the patient to generate a greater force to expel secretions. Technique 2. The patient places her forearms over her abdomen. As the patient tries to cough, the patient pulls downward with her upper extremities to assist with force production. This can be completed in either a supine or a sitting position. This technique can also be modified by having the patient fall toward her knees as she attempts to cough. This is illustrated in Intervention 12-2, A. Technique 3. In a prone on elbows position, the patient raises her shoulders, extends her neck, and inhales. As the

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patient coughs, the patient flexes her neck downward and leans onto her elbows. Technique 4. If the patient is unable to master any of the pre- viously mentioned assistive cough techniques, a caregiver can assist the patient with secretion expulsion. A modified Heimlich maneuver can be performed by placing the care- giver's hands on the patient's abdomen just below the rib cage and providing resistance in a downward and upward direction to the cough effort (see Intervention 12-2, B). Percussion, vibration and shaking

patient coughs, the patient flexes her neck downward and leans onto her elbows. Technique 4. If

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Percussion, vibration and shaking of the chest wall are used to improve secretion clearance. Passive movement

Percussion, vibration and shaking of the chest wall are used to improve secretion

clearance.

Passive movement and stretching

Percussion, vibration and shaking of the chest wall are used to improve secretion clearance. Passive movement

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Positioning: The supine position (Fig. 4.1A) 17

Positioning:

The supine position (Fig. 4.1A)

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When supine, the patient is positioned in the following way. Lower limbs ● Hips – extended

When supine, the patient is positioned in the following way.

Lower limbs ● Hips – extended and slightly abducted ● Knees – extended but not hyperextended ● Ankles – dorsiflexed

● Toes – extended. One or two pillows are kept between the legs to maintain abduction

and prevent pressure on the bony points, i.e. medial condyles and malleoli.

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The side-lying or lateral position (Fig. 4.1B) When lying on the side, the patient is positioned in the following manner. Lower limbs

● Hips and knees – flexed suffi ciently to obtain stability with two

pillows between the legs and with the upper leg lying slightly behind the lower one

● Ankles – dorsiflexed ● Toes extended.

Turning in bed

The side-lying or lateral position (Fig. 4.1B) When lying on the side, the patient is positioned

In patient phase

The same as icu plus a-lower limb strengthening exs

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Myotome

Myotome b- sensory reeducation program according to princibles of neurology by Hassan Elwan 20
Myotome b- sensory reeducation program according to princibles of neurology by Hassan Elwan 20

b- sensory reeducation program according to princibles of neurology by Hassan Elwan

Myotome b- sensory reeducation program according to princibles of neurology by Hassan Elwan 20

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L1

Upper 1/3 front of thigh

L2

Middle 1/3 front of thigh

L3

Lower 1/3 front of thigh

L4

Antero-lateral aspect of thigh, front of knee, antero-medial aspect of leg, medial aspect of foot and big toe

L5

Lateral aspect of thigh, lateral aspect of leg, middle 1/3 of dorsum of foot and middle 3 toes

S1

Postero-lateral aspect of thigh and leg, lateral 1/3 of dorsum of foot and little toe

S2

Posterior aspect of thigh, leg and sole of foot

S3, 4, 5

Anal, peri-anal and gluteal region (saddle shaped area)

3- Training for postural control

3- Training for postural control

The terms„„balance‟‟,,„„equilibrium‟‟ and„„postural control‟‟ are used as synonyms for the same concept

of the mechanism by which the human body prevents itself from falling or loosing balance ((Ragnarsdottir Ragnarsdottir 1996)

POSTURAL CONTROL

““controlling the body‟s position in space for the dual purposes of stability and and orientation”

POSTURAL ORIENTATION

This involves This involves

►► The ability to maintain the appropriate alignment between body segments

►► The appropriate relationship between the body and the environment ..

►► Requires establishing a vertical orientation to counteract the to counteract theforces of gravity. ►► Creates a reference frame for

perception and action with respect to the external world.

POSTURAL STABILITY

This involves►►Maintaining the body‟s centre of

mass within boundaries of space, referred to as referred to as stability limits.

►►Stability limits are boundaries of an area of space in which the body can maintain it‟‟s position without changing it‟‟s base of support

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impairments of postural control in low level para plegia secondary to weakness and sensory disturbance

Good trunk control ■ Total control of upper extremities ■

Partial to full control of lower extremities ■ Imparirment of pelvis control Impairment in standing control Impairment in locomotion and gait

A pelvis control Kneeling: Prerequisite Requirements

Prior to the use of kneeling as an activity, several important requirements for assuming the posture need consideration. Full hip flexor ROM is necessary: if limitations exist. the patient's ability to achieve the needed hip extension will be compromised. Sufficient strength'of the trunk and hip extensor muscles is necessary to keep the head and trunk upright and the hips extended. This is partiCularly important given the relative anterior instability inherent in the posture. Although kneeling provides an important opportunity for improving posture and balance control. adequate static postural control (ability to keep the COM over the BOS) is needed for initial maintenance of the upright posture.

A Kneeling, Assist-to·Position ACTIVITIES, STRATEGIES, AND VERBAL CUES FOR KNEELING, ASSIST-TO-POSITION FROM BILATERAL HEEL-SIDING

Activities and Strategies For assisted movement transitions into kneeling, both the patient and the therapist are initially positioned in heel-sitting facing each other (Fig. 5.2A).

The therapist places one hand on the posterior upper trunk passing under the axilla: the opposite manual contact is on the contralateral postel;or hip/pelvis. These hand placements allow the therapist to assist with lifting the trunk into the up- right position as well as with moving the patient's hips toward extension. The patient's hands are supp0l1ed on the therapist's shoulders, which assists in guiding the upper trunk in the de- sired direction of movement. The patient and therapist then move together into a kneeling position (Fig. 5.2B).

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Position/Activity: Kneeling, Weight Shifting Weight shifting in kneeling is a closed-chain exercise that involves motions in

Position/Activity: Kneeling, Weight Shifting

Weight shifting in kneeling is a closed-chain exercise that involves motions in which the distal part (knees) is fixed while the proximal segment (pelvis) is moving. Weight shifting activities provide the important benefit of promoting the simultaneous action of synergistic muscles at more than one joint. In addition, the joint approximation and stimulation of proprioceptors further enhance joint stabilization (cocontraction).

Since the kneeling posture must be stabilized while moving. weight shifting also improves dynamic stability.

Position/Activity: Kneeling, Weight Shifting Weight shifting in kneeling is a closed-chain exercise that involves motions in

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Kneel walking 27

Kneel walking

Kneel walking 27

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Half kneeling General Characteristics The posture is more stable than kneeling. Half-kneeling involving, head. trunk. and

Half kneeling General Characteristics

The posture is more stable than kneeling. Half-kneeling involving, head. trunk. and hip muscles for upright postural control. The head and trunk are maintained on the vertical in midline orientation with normal spinal lumbar and thoracic curves. The pelvis is maintained in midline orientation with the hip fully extended on the posterior stance limb. As with kneeling. static postural col/trol is necessary for the maintenance of upright posture. Dynamic postural control is necessary for control of movements performed in the posture

(e.g

weight shifting or reaching). Reactive balance control is needed for adjustments in response to changes

.. in the COM (perturbation) or changes in the SUpp011 surface (tilting). Anticipatory balance control is needed for preparatory postural adjustments that accompany voluntary movements.

Half-Kneeling. Assist-to-Position Assist-to-position mo\ement transitions into half-kneeling can be effectivel) accomplished from a kneeling position. This movement transition is an important lead-up skill to in- dependent floor-to-standing transfers.

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b-Standing control General Characteristics 31
b-Standing control General Characteristics 31

b-Standing control General Characteristics

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It is important to understand the formational requirements of standing. Standing is a relatively stable posture

It is important to understand the formational requirements of standing. Standing is a relatively stable posture with a high center of mass (COM) and a small base of support (BOS) that includes contact of the feet with the support surface.

During normal symmetrical standing. height is equals distributed over both feet (Fig. 7.1). Front Ll lateral \ iert. the line of gravity (LoG) falls close to tttost joint axes: slightly anterior to the ankle and knee joints. slightly posterior to the hip joint. and posterior to the cervical and lumbar \enebrae and anterior to the thoracic vertebrae and atlanto-occipital joint

(Fig. 7.2). Natural spinal curves (i.e

normal lumbar and cervical lordosis and normal thoracic kyphosis) are present but

.. flattened in upright stance depending on the level of ppstural tone tone. The pelvis is in neutral position. with no anterior or posterior tilt. Normal alignment minimi/.es the need for mus- cle activity during erect stance. Postural stability in standing is maintained by muscle activity that includes: ll) postural tone in the antigravity muscles throughout the trunk and lower extremities . and (2) contraction of antigravity muscles. The gluteus maximus and hamstrings contract to tnaitttain pel\ic alignment; the abdominals contrarct to flatten the lumbar curve: the paravertebral muscles contract to extend the spine. ‘its quadriceps muscles contract to maintain knee extension the hip abductors contract to maintain pelvic alignment dur- ing midstance and during lateral displacements.

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Normal Postural Synergies

Normal postural strategies for maintaining upright stability

and balance include:

~ Ankle strategy involves small shifts of the COM by rotat- ing the body about the ankle joints: there is minimal movement of the hip and knee joints. Movements are well within the LOS (Fig. 7.3A).

  • - Hip strategy involves larger shifts of the COM by flexing

or extending at the hips. Movements approach the LOS (Fig. 7.3B).

  • - Change ofsupport strategies are activated when the COM

exceeds the BOS and strategies must be initiated that reestablish the COM within the LOS. These include the stepping strategy, which involves realignment of the BOS under the COM achieved by stepping in the direction of the instability (Fig. 7.3C). They also include UE grasp strategies. which involve attempts to stabilize movement of the upper trunk. keeping the COM over the BOS. STANDING A PATIENT WITH A KNEEANKLEFOOT ORTHOSIS

Standing between parallel bars

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Exercises in standing Balance exercises Exercises for strength and control Before commencing gait training, the patient

Exercises in standing Balance exercises Exercises for strength and control Before commencing gait training, the patient must learn to tilt his pelvis by using latissimus dorsi, and to become aware of the degree of control he can achieve with this compensatory mechanism. Pelvic side tilting Resisted trunk exercises

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Transfer training Overview of Biomechanics It is important to have a good understanding of the normal

Transfer training

Overview of Biomechanics

It is important to have a good understanding of the normal biomechanics of the sit-to/from-stand motion. The physical

therapist uses this information as part of the task analysis to compare how the patient is performing the task and to identify possible impairments that may be causing the activity limitations observed. Sit-to-stand is commonly broken down into two phases: pre-extension and extellsion.

The preextension phase involves a forward or horizontal translation of body mass, and the extension phase involves a vertical translation of body mass. The point in time when the thighs

come off the sitting surface (thigh off) is the transition between the two phases. It should be kept in mind that this

breakdown into two distinct pha",>, i, done to organize the clinical analysis of the mo\ement. ~ormally. the movement

occurs in one smooth motion.

Initially, the majority of the bod~ mass is resting on the thighs and buttocks in a stable ,itting posture (Fig. 6.3A).

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During the pre-extension phase. the upper body (head and trunk) rotates forward at the hip joint and the lower legs ro-

tate forward over the ankle joinh (dorsitlexion) (Fig. 6.3B).

Once the trunk and head rotate forward. causing the body mass to translate horizontall). the extension phase begins,

with extension at the knees, closely followed by extension at the hips and ankles." The thighs come off the seat (Fig.

6.3C).

During the extension phase, the greatest muscle force occurs to lift the body mass up off the sitting surface. During the rest of the extension phase (Fig. 6.30), the hips and ankles con-

tinue to extend together with the knees to bring the body to an upright posture.

During the pre-extension phase, the iliopsoas and tibialis anterior are the primary muscles activated to propel the body

mass forward. The trunk extensors and abdominal muscles contract isometrically to stabilize the trunk while it rotates forward at the hips. During the extension phase, the hip (gluteus maximus), knee (rectus femoris, vastus lateralis, and vastus medialis), and ankle extensors (gastrocnemius and soleus) are

activated to lift the body up to standing.

People generally utilize two basic strategies to transfer from sitting to standing: momentum-transfer strategy and

zero-momentum strategy.3 The momentum-transfer strategy involves generating forward momentum as the trunk and

head translate in a horizontal direction (flexion at the hips) causing the center of mass (COM) to shift toward and over

the feet. The trunk extensor muscles then contract eccentrically to brake the horizontal motion. This is followed by a

strong concentric contraction of the extensor muscles of the LEs to lift the body vertically.

The zero-momentum strategy entails forward flexion of the trunk until the COM is within the base of support

(BOS) of the feet. Then there is a vertical lift of the body mass into a standing position. The zero-momentum strategy

is more stable than the momentum-transfer strategy but requires greater muscle force to perform. Individuals with

LE weakness who utilize this strategy may also require arm-rests to push off of with their upper extremities (UEs). The

momentum-transfer strategy requires less force because the body is in motion as the legs begin the lift. However, there

is a trad -off with stability. The person is less stable during the transition period.

The motion (angular displacement) of transitioning from standing to sitting is similar to the motions that occur

during -it-to-stand. only in reverse! However, the timing and type of muscle contraction are different. While transi-

tioning from tanding to sitting, the body mass is moving backward and downward. Flexion of the hips, knees, and ankle is controlled by eccentric contraction of the LE extensor muscles.

Additionally, the patient cannot directly see the surface upon which he or she is about Lo sit.

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Task Analysis of Sit to and From

Stand Transfers

Movement tasks can generally be broken down into four stages: initial conditions, initiation, execution, and termina-

tion.

Task Analysis of Sit to and From Stand Transfers Movement tasks can generally be broken down
Task Analysis of Sit to and From Stand Transfers Movement tasks can generally be broken down

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To transfer from chair to crutches An unaided exit from a chair is essential if crutch

To transfer from chair to crutches

An unaided exit from a chair is essential if crutch walking is to be

functional. There are three techniques used to get into and out of the

chair with crutches:

● forwards technique

● sideways technique

● backwards technique.

All three methods are taught where possible, and the patient chooses

that which he finds easiest.

Forwards technique

Severe abdominal and/or flexor spasticity which prohibits the necessary hyperextension at the hips, or excessive height, may prevent a patient accomplishing this technique.

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Sideways technique 64
Sideways technique 64

Sideways technique

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Backwards technique 65
Backwards technique 65

Backwards technique

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To get do wn and up from the floor onto crutches Crutches to floor To get
To get do wn and up from the floor onto crutches Crutches to floor To get

To get down and up from the floor onto crutches

Crutches to floor

To get out of a car onto crutches

  • 1. Turn to face the open door and lift the legs out of the car.

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  • 2. Lock the knee joints.

  • 3. With the window open, use the window ledge and the back of

the seat, or the seat and a crutch, to lift into standing.

  • 4. Balance with the hips hyperextended and take hold of each

crutch in turn.

2. Lock the knee joints. 3. With the window open, use the window ledge and the
2. Lock the knee joints. 3. With the window open, use the window ledge and the

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Gait training GAIT There are three types of gait used: ● swing -to gait ● four

Gait training

Gait training GAIT There are three types of gait used: ● swing -to gait ● four

GAIT

There are three types of gait used:

● swing-to gait

● four-point gait

● swing-through gait.

Controlled walking is achieved only through perseverance, perfect

timing, rhythm and coordination. The patient is taught always:

  • 1. to move the hands first

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2.

to walk slowly and place his feet accurately

3.

to take the weight through the feet and so ensure that the hands can relax between each step

4.

to lift the body upwards and not to drag the legs forwards.

An accurate technique must be achieved in bars if crutch walking is

 

to be successful.

Where it is anticipated that the patient will become an accomplished walker, it is usual to commence training with the four-point gait.

It is easier to learn to use the latissimus dorsi muscles at first separately and then together than vice versa.

GAIT TRAINING IN THE BARS

 

Swing-to gait

This is the universal gait because it is both the simplest and the safest.

All patients with lesions above T10 are normally taught this gait

 

rst.

The therapist

The therapist stands behind the patient with her hands over the iliac

crests. Assistance is given to lift, to control the tilt of the pelvis and

to transfer weight as necessary (Fig. 13.6AC).

 

Action of the patient

1.

Balance in the hyperextended position.

2.

Move the hands, either separately or together, forward along the

bars approximately half a foot length in front of the toes.

3.

Lean forward, with the head and shoulders over the hands (Fig. 13.6D), and lift the legs, which will swing forward to

follow the position of the head and shoulders. The step is short and the feet must drop just behind the level of the hands (Fig. 13.6E). To achieve this, the lift must be released quickly, otherwise the feet will travel too far and land

between or in front of the hands.

When on crutches, it is unstable and therefore dangerous to have the feet and hands in line. It must therefore be avoided in the bars. The swing-to gait is a ‘staccato’ gait with no follow through:

‘lift and drop’.

The patient should also be taught to swing backwards along the bars.

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To turn in the bars The turn is achieved in two movements by turning through 90°
To turn in the bars The turn is achieved in two movements by turning through 90°
To turn in the bars The turn is achieved in two movements by turning through 90°

To turn in the bars

The turn is achieved in two movements by turning through 90° each

time.

To turn to the right:

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  • 1. Place the left hand forward about a foot length along the bars and

the right hand either level with or a little behind the trunk.

  • 2. Lift and twist the shoulders and upper trunk to the right. The feet land facing the bar to the right (Fig. 13.7A).

  • 3. Balance in this position and move the left hand across to the right bar (Fig. 13.7B).

  • 4. Twisting the upper trunk to the right, place the right hand on the opposite bar.

  • 5. Lift the feet round to a central position between the bars (Fig. 13.7C).

Benefits of Body Weight Support (BWS) and a Treadmill

1. Place the left hand forward about a foot length along the bars and the right

GAIT USING FUNCTIONAL ELECTRICAL STIMULATION

1. Place the left hand forward about a foot length along the bars and the right

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(FES) STANDING SYSTEMS For the past 30 years, experiments have been undertaken to enable patients to

(FES) STANDING SYSTEMS

For the past 30 years, experiments have been undertaken to enable patients to walk using electrical stimulation of the relevant muscles.

Surface, nerve cuff and deep muscle electrodes have been used. FES is applied to the intact lower motoneurone pathways and is therefore only suitable for upper motoneurone paralysis, as with stimulation

of the phrenic nerve . Initially, FES is used to improve the condition and bulk of the paralysed muscles. When the state of the muscles has improved, electronic implants can be used to activate muscles in functional sequence. Interestingly, 50 years ago Sir Ludwig Guttmann showed that muscle bulk could be improved in rabbits

(Guttmann & Guttman 1942) and later in humans using galvanic stimulation (Guttmann & Guttman 1944).

Surface stimulation

Root stimulation gives access to the whole motor output, whilst surface stimulation reaches only part of it. Usually the gluteal and hamstring muscles are stimulated for standing, and quadriceps and

the flexor withdrawal response for walking. To stimulate more muscles is impractical as it is too time-consuming. Surface stimulation is wasteful of current and requires assiduous attention to skin

care, and the stimulation varies with movement of the limbs (Rushton et al 1995).

As surface stimulation methods are essentially limited to experimental work and for assessment, the electrode system must be implanted to obtain consistent and selective results.

Implanted electrodes

Three types of implanted electrodes are used:

● Percutaneous wires are inserted through the skin and focused on a motor point. Any number of wires may be used. Formal surgery is not required and the wires are inserted easily by a practised operator.

This procedure has a high risk of electrode failure and a high incidence of infection. Cosmesis is unacceptable (Barr et al 1995).

● The nerve cuff electrode is placed around peripheral nerves in a formal surgical procedure.

● The epimysial electrode (disc type of electrode) is placed near the motor point of large muscles. Less dissection is required than for the cuff type but multichannel lower limb systems still require extensive

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surgery and the cabling also has to be implanted in the limb. As cable connectors tend to fracture, further surgery is often required.

A sacral anterior root stimulator implant (SARSI) has been widely

used to restore bladder control in male and female patients and erectile function in male patients (Brindley & Rushton 1990). A lumbar anterior root stimulator implant (LARSI) has been used to stimulate

lumbar and sacral roots (L2S2) to restore lower limb function in two patients. These systems are now commercially available, as are some surface and upper limb motor locomotor systems.

Stringent criteria are necessary for the selection of patients for any FES system, which will include psychological as well as physical assessments. For example, joints must have full range of movement

and be free of osteoporosis and the patient must be physically fit, as energy consumption is high. Patients gain the usual benefits from standing and walking with these systems, and Jaeger et al (1990)

found psychological benefi ts also, in that the patients’ self-esteem and confidence appeared to increase. To use a surface system long term is impractical, but surface stimulation as a non-invasive means of

assessment and training is necessary for an implant system (Barr et al 1995). Both systems are useful and in many ways complementary (Rushton 1996).

FES does not restore functional gait. It is a form of exercise and remains experimental. Whatever the technique used, walking speed is slow and, together with energy consumption, is a limiting factor.

Major technical problems continue to be encountered, for example in the selection and control of stimulation, failure of equipment and muscle fatigue.

To replace the intricate mechanism of normal gait is an enormous

task. It is not surprising that progress is slow. Research continues in

many centres worldwide.

Hybrid Assistive Limb

.

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Lokomat 79

Lokomat

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The Lokomat uses a robot to automate treadmill training, giving patients longer and more frequent sessions

The Lokomat uses a robot to automate treadmill training, giving patients longer and more frequent sessions and resulting in a faster and improved return to mobility. The robot intelligently adapts its behavior to the patient’s individual capabilities.

The walking with Lokomat is said to improve pelvis and hip actuation as the walking is more natural, and the virtual training environments can increase patients’ motivation and engagement.

The Lokomat uses a robot to automate treadmill training, giving patients longer and more frequent sessions

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Four-point gait This gait is the slowest and most difficu lt of all and is only

Four-point gait

This gait is the slowest and most difficult of all and is only achieved on crutches by accomplished walkers. It facilitates turning and manoeuvring in confi ned spaces. It also provides an excellent training

exercise in strength, balance and control.

The therapist. The therapist holds the pelvis in the usual way. Both by instruction and by correction with her hands, the therapist emphasizes each move, ensuring that the patient achieves it correctly. Only

when the patient consistently makes a single movement correctly does the therapist stop correcting that component. The patient needs to see and ‘feel’ the correct posture at each move, and therefore constant

repetition is necessary.

Action of the patient

To take a step forward with the left leg

  • 1. Place the right hand forward about half a foot length along the bar and the left one just in front of the hip joint.

  • 2. Take the weight on the right leg, so that the hip is over the right foot and the knee and ankle in a vertical line.

  • 3. With the left shoulder slightly protracted, push on the left hand and depress the shoulder (Fig. 13.6F, p. 227). The

effort is to ‘lift’ the leg upwards.

  • 4. As the left leg is lifted, it swings forward to follow the shoulder. The ‘lift’ is released when a large enough step has

been made. (Small steps should be taken initially, but the foot must always land in front of the hand.)

  • 5. Take the weight over the left leg.

  • 6. Move the left hand forward along the bar in preparation for moving the right leg. Pelvic rotation must be avoided.

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The following are possible reasons for an inadequate lift:

● some weight remains on the moving leg

● the hands are too far forward

● the weight may be over the toes and not back over the heels, in which case the trunk may be hyperextended and the legs consequently inclined too far forward

● insuffi cient depression of the shoulder girdle on the side of the moving leg

● the bars are too high or too low

● the lift is not held for suffi cient time to allow the leg to swing forward.

To take a step backward with the left leg

  • 1. Place the left hand slightly behind the hip joint.

  • 2. Lift the leg and at the same time lean forward on that side.

  • 3. Bend the elbow and ‘flip’ the leg backwards.

Swing-through gait

This gait requires skilled balance, but it is the fastest and most useful.

The therapist

The therapist gives assistance where necessary with her hands controlling the pelvis until the patient can accurately and slowly perform the movements. The forward thrust of the pelvis to push the

weight over the feet usually needs to be emphasized.

Action of the patient

  • 1. Place the hands forward along the bars as for the swing-to gait.

  • 2. Lean forward and take the weight on the hands.

  • 3. Push down on the bars, depress the shoulder girdle and lift both legs. The lift must be sustained until the legs have

swung forward to land the same distance in front of the hands as they were originally behind. Considerably more

effort is required than for the swing-to gait.

  • 4. As the weight is lifted and the legs swing forward, hyperextend the hips, extend the head and retract the shoulders.

  • 5. To move the trunk forward over the feet, push on the hands, extending the elbows and adducting the

shoulders. When the weight is fi rmly on the feet, move the hands along the bars for the next step.

GAIT TRAINING ON CRUTCHES

Progression is made to crutch walking only when the technique

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between the bars is good. The height of the elbow crutches is checked

as for the bars.

The change from walking in bars to crutch walking is considera-

ble, and all patients are initially unstable and fearful. A high degree

of balance skill is essential and this is only achieved with perseverance and much practice.

Balance exercises

Balance on crutches is trained in the same way as when balancing in the bars (Fig. 13.8A). Resisted work is also given to enable the patient to gain adequate control over the trunk and pelvis.

Walking on crutches

Swing-to and four-point gaits are taught first and progression is made to swing-through (Fig. 13.8B, C). Until the new postural sense is established training is again carried out in front of a mirror.

Progression in the four-point gait may be made by using one bar and one crutch if preferred. Otherwise, progression is directly onto two crutches, as there is less tendency to trunk and pelvic rotation.

The technique for each gait is the same as already described for walking in bars. Much greater skill is required and several weeks of practice will be needed to acquire the necessary balance and coordination.

between the bars is good. The height of the elbow crutches is checked as for the

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Stairs Climbing stairs is normally functional for patients with good abdominal muscles. Some young and active

Stairs

Climbing stairs is normally functional for patients with good abdominal muscles. Some young and active patients with lesions between T6 and T10, with or without a spinal brace, may also become effi cient and independent. Patients can climb the stairs either forwards or backwards.

The forwards technique is usually taught first because it has the advantage that the patient can see where he is going. Most agile patients with good abdominal muscles will learn both methods and make their own choice. Where there is severe abdominal and/or hip flexor spasticity, the degree of hyperextension easily obtainable at the hip joints may be too limited for the forwards technique.

Two rails are used initially, progression being made to one rail and one crutch. Finally, the second crutch must be carried, usually in the crutch hand, as illustrated in Figure 13.13.

The therapist always stands behind the patient. She holds the trouser band or a therapeutic belt with one hand and grasps the patient round the waist with the other. After the initial attempts,

both hands should be placed around the pelvis in the usual position for greater control. Assistance is given, as necessary, until the technique is mastered.

Forwards technique using one rail and one crutch

To walk upstairs

1. Standing close to the rail, grasp it approximately half a foot length in front of the toes.

2. Place the right crutch on the stair above, level with the hand on the rail (Fig. 13.13A). The hands must be level to avoid

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trunk rotation when lifting. The tendency to grasp the rail too far forward and ‘pull’ must be avoided.

  • 3. Lean over the hands and lift as high as possible, keeping the trunk and pelvis in the horizontal plane (Fig. 13.13B).

  • 4. As soon as the feet land on the stair above, hyperextend the hips to find the balance point (Fig. 13.13C).

To walk downstairs

  • 1. Standing close to the rail and keeping the body in the horizontal plane, place the right crutch close to the edge of the

same stair.

  • 2. Place the left hand down the rail on a level with the crutch (Fig. 13.13D).

  • 3. Lift and swing the feet down to the stair below (Fig. 13.13E).

  • 4. Hyperextend the hips and retract the shoulders as soon as the feet touch the ground (Fig. 13.13F).

Very short patients may need to put the crutch on the stair below the feet and lift down to the crutch.

Backwards technique using one rail and one crutch

To walk upstairs

  • 1. Balance in hyperextension whilst placing the left hand higher up the rail and the crutch on the stair above, keeping

the hands level (Fig. 13.13F).

  • 2. Lift backwards (Fig. 13.13E).

  • 3. Regain the balance (Fig. 13.13D).

To walk downstairs

  • 1. Place the crutch on the edge of the same stair as the feet, with the hands level (Fig. 13.13C).

  • 2. Lift the feet backwards to the edge of the stair.

  • 3. Lean forward on the hands, lift and ‘fl ick’ the pelvis backwards (Fig. 13.13B).

  • 4. Drop the feet onto the stair below (Fig. 13.13A).

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