About the Book

• Written in simple language and lucid style.
• Deals with the treatment of patients with hemiplegia using various physiotherapeutic techniques.
• Useful in integrating different treatment approaches along with treatment protocol.
• Well illustrated with clinical photographs of actual patients treated by the author himself.
• Excellent quick reference guide for physiotherapists and undergraduate and postgraduate students

About the Author

Ipsit Brahmachari PhD

Table of Contents:
Basic Anatomy and Physiology of Human Brain .................................. 1 Anatomy of the head 1 The major regions of the brain and their functions 4 The cerebral circulatory system 7 The neonatal brain 9 Aspects of neuroanatomy and physiology 10 2. The development of nervous system....................................................... 17 Development of movement, posture and developmental neurology 17 Neonatal reflexes 21 Discussion of developmental sequences and its importance in treatment planning of the patient 23 The clinical value of knowledge of developmental sequence 27 3. Clinical Aspects of Stroke: A Major Cause of Hemiplegia ............... 29 Definition 30 Types of stroke 30 Less frequent causes of stroke 32 The stroke-prone population 33 Risk factors for Cerebrovascular disease 34 Causes of ischemic stroke 35 Threatened stroke 36 Stroke mimics 38 Stroke in the young Indian population 38 Other unusual causes of stroke in children 38 Stroke with atypical presentation 39 4. Clinical Diagnosis of Neurological Condition ....................................... 41 Bedside assessment of stroke 41 Neurological case history 42 The neurological examination 43 Physical examination 44 Neurological examination and stroke scale scores 45 Diagnostic tests 45 Further tests 46 5. Symptoms of Brain Damage .................................................................... 49 CNS disorders and Brodal’s passage 49 Sites of lesion and clinical manifestation 53xii A Practical Guide to Hemiplegia Treatment Signs and symptoms and structures involved 54 Sequential stages 60 Alterations in tone of the muscles 61 Loss of selective movement 62 Synergy patterns 63 Reflexes 63 Weakness 65 Incoordination 66 Dystonia 66 Motor programming deficits 67 Functional abilities 67 Speech and language disorders 68 Perceptual deficits 68 Cognitive and behavioral changes 69 Bladder and bowel dysfunction 71 Orofacial dysfunction 71 Patterns of behavior in right and left brain 72 Secondary impairments 72 Recovery from stroke 76 6. Essentials of Assessment ............................................................................ 77 Physical therapy assessment 77 Assessment of normal postural reflex mechanism 84 Short assessment and treatment planning for adult hemiplegia (Bobath assessment form) 86 7. Management and Rehabilitation Medicine ............................................ 98 Medical management 98 Philosophy of rehabilitation medicine 99 Areas of Rehabilitation 101 Aspects of rehabilitation 102 Impairment, disability and handicap 102 Rehabilitative management 103 The rehabilitation team 104 Ethical value system in patient care 109 8. A Systematic Approach to Treatment ................................................... 110 Approach to treatment 110 9. Treatment Program in Acute Stage ...................................................... 139 During NICU and TCU stay 139 Pulmonary or chest physiotherapy 141 Positioning 143 Passive range of motion exercises 148 Range of motion and prevention of limb trauma 150 Start with the midline 152 Do’s and Don’ts 153Contents xiii 10. Activities in Lying..................................................................................... 155 Brushing 155 Icing 156 Connective tissue release 156 Neural tissue stretch 160 Sustained stretch 161 Pressure over body parts 162 Selective trunk activity 163 Correction of anterior chest position in lying 164 Rib cage alignment 165 Mobilization of thorax 165 Mobilizing the arm 166 Proprioceptive neuromuscular facilitation (PNF) pattern activities 169 Side-lying activities 170 Scapular mobilization 172 Activation of lower trunk 180 Lower extremity control 187 Elongation of trunk and pelvic clock exercises 194 Use of the ball in training lower limb and trunk in lying 197 11. Activities in Sitting ................................................................................... 200 Training of lying to sitting using trunk 200 Sitting from side-lying 201 Sitting in the bed 202 Moving sideways in sitting 202 Transfer activities 203 Upper extremity control 204 Control of quadriceps in long sitting 205 Inhibition of extensor thrust 206 Weight shifts in high sitting 207 Simultaneous activation of upper limb and trunk 208 Weight-bearing through upper extremities 210 Upper extremity placing 211 Dynamic balance reactions 212 Moving lower limb 214 Weight shift on elbows, sideways 215 Sitting in the chair 215 Weight transference on affected upper limb with reachouts 216 Moving in sitting position 217 Weight transference through the arms behind 218 Neck stretching 218 Activation of wrist extensors 219 Shoulder activities 220 Preparation for hand activity 221 Forearm supination and elbow flexion 223 Shoulder external rotation activities 224xiv A Practical Guide to Hemiplegia Treatment Use of elastic band in applying resistance 224 Use of a ball in applying resistance 225 Use of stretch reflex 227 Use of bilateral upper limb activities 228 Moving the hand 229 Activities on vestibular ball 231 Foot movements 241 Activities on mat 242 Training for dorsiflexion of foot 245 Specific activities for patients with sensory involvement 245 Activities for recovering arm 250 Functional training 253 12. Activities in Standing ............................................................................... 255 Training from sitting to standing 255 Pelvic alignment in standing 259 Unilateral weight bearing 260 Assisted activities with the help of a table 261 Step-up activities 264 Weight bearing on the affected leg 265 Training plantar flexion 267 Training selective knee flexion in standing 268 Dynamic activities for lower limb control and gait 269 Stairs 280 Dynamic balance activities 281 PNF wood chopping 285 Upper limb activation 285 Obstacle walking 292 Strengthening exercises using resistive tubing 293 Advanced functional training 295 Group therapy 297 13. Proprioceptive Neuromuscular Facilitation (PNF) Activities ............ 294 Flexion—abduction—external rotation 298 Flexion—abduction—external rotation with elbow extension 299 Flexion—adduction—external rotation with elbow flexion 300 Flexion—adduction—external rotation with elbow extension 300 Extension—abduction—internal rotation with elbow extension 301 Bilateral symmetrical: Flexion—abduction—external rotation 302 Bilateral asymmetrical: Flexion—abduction—external rotation with the right arm; flexion—adduction—external rotation with the left arm 302 Flexion—abduction—external rotation at end ranges, lying prone on elbows 303 Flexion—abduction—internal rotation 303 Flexion—abduction—internal rotation with knee flexion 304 Flexion—abduction—internal rotation with knee extension 304Contents xv Extension—adduction—external rotation 305 Flexion—adduction—external rotation with knee flexion 305 Flexion—adduction—external rotation with knee extension 306 Extension—abduction—internal rotation 307 Extension—abduction—internal rotation with knee extension 307 Extension—abduction—internal rotation with knee flexion 308 Bilateral symmetrical leg patterns: Flexion—abduction with knee extension in sitting 308 Bilateral asymmetrical patterns: Flexion—abduction with knee extension on the left; extension—abduction with knee flexion on the right 309 Bilateral symmetrical pattern in supine—flexion—abduction 309 Leg patterns in sitting: Extension—adduction with knee flexion 310 Leg patterns in sitting: Extension abduction with knee flexion 310 Flexion—adduction with knee extension 311 Patterns of trunk 311 Bilateral leg patterns for trunk in lying 312 Bilateral leg patterns for trunk in sitting 312 Combining patterns for the trunk 313 Resistive patterns on mat 313 14. Orofacial Rehabilitation ........................................................................... 314 Respiratory and oromotor activities 314 Muscles of facial expressions 315 Stimulation of lips and oral cavity (Vibration and icing) 319 Resisted tongue movements 321 Chewing and deglutition 322 Activities for coordination of eye movements 323 15. Perceptual Dysfunctions and Treatment............................................... 326 Somatosensory dysfunction 326 Perceptual disabilities: Site and side of lesion 327 Body scheme and body image disorders 329 Unilateral visual or spatial neglect 330 Right-left discrimination 333 Finger agnosia 334 Anosognosia 334 Spatial relations deficits 335 Agnosia 342 Apraxia 344 Cognitive dysfunction 350 Strategies to improve communication in a patient having speech disorder 352 Therapeutic guiding techniques 352xvi A Practical Guide to Hemiplegia Treatment 16. Complications and their Management .................................................. 354 Shoulder pain 354 The subluxated shoulder 355 Shoulder hand syndrome (reflex sympathetic dystrophy) 357 Fractures 358 Thalamic pain syndrome 358 Outburst of laughing and crying 359 Tightness-contractures-deformity 359 Pusher’s syndrome 360 17. Adjunct Therapies..................................................................................... 362 Biofeedback 362 Electrical stimulation 363 Isokinetics 365 Music as therapy 366 Exercise conditioning 366 Robotics and computer-aided therapy 367 Constraint-induced therapy 368 Motor relearning 368 Hydrotherapy 369 Orthosis in hemiplegia 370 Botulinum injections for spasticity 375 Other allied therapies 382 18. Hemiplegia Care at Home ...................................................................... 384 Merits of home treatment 384 Demerits of home treatment 385 Treatment plan 386 Problems associated with home-based treatment 386 Suggested solutions 389 Physiotherapist 390 19. Orthopedic Management of Stroke ....................................................... 397 Evaluation 398 Management of spasticity during the period of physiologic recovery 400 Management of residual deformities 403 Commonly seen residual deformities and their management 404 Author’s perspective 416 20. Conclusion .................................................................................................. 417 Place where initial physiotherapy was carried out 418 Physiotherapy to be carried out by qualified physiotherapist 419 Involvement of rehabilitation professionals other than physiotherapist 419 Awareness about helpfulness of rehabilitation professionals 420 Satisfaction with rehabilitation 420 Awareness about different physiotherapy techniques amongst patients 421 Sexual functions in hemiplegics 422 Psychological aspects of hemiplegia 423Contents xvii Social functions 424 Spirituality and faith 426 Work and profession 427 Functional recovery 428 An ideal rehabilitation of a person suffering from hemiplegia 429 21. Assessment Scores and Scales ................................................................ 434 ABCD score 434 The Barthel index 435 Beck’s depression inventory 437 Berg balance scale 440 The European stroke scale 443 Family assessment device 447 The Frenchay activities index 453 Geriatric depression scale (short form) 454 Glasgow coma scale 455 Hemispheric stroke scale 456 Hunt and hess scale 461 Mathew stroke scale 462 Mini-mental state examination (MMSE) 464 Modified Rankin scale (MRS) 466 Motor assessment scale 467 Motricity index 471 NIH stroke scale 472 Orgogozo stroke scale 475 Rivermead mobility Scandinavian stroke scale 480 Tinetti balance assessment tool 482 The trunk control test for motor impairment after stroke 484 Stroke impact scale 485 Functional independence measure (FIM) 489 Berg balance 490 The rehabilitation index 490