A Practical Guide To Hemiplegia Treatment

Contents i
A Practical Guide to
HEMIPLEGIA TREATMENT
A Practical Guide to
HEMIPLEGIA TREATMENT
Ipsit Brahmachari PhD

Physiotherapist
Proprietor
Marg Physiotherapy and Rehabilitation Clinic
Ahmedabad, Gujarat, India
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A Practical Guide to Hemiplegia Treatment

First Edition: 2015
ISBN 978-93-5152-412-0
Printed at
Dedicated to
My Teachers
and
My Patients
Preface
Physiotherapy is a field of science dealing with physical agents and using
them to bring about positive changes to the health of the receiver. Hence,
it has to be highly objective in nature and its results should be reproducible
on application of same treatment techniques on similar conditions. However,
it does not hold true in clinical practice. It is observed by every physiotherapist
that a similar technique can bring about dissimilar results in patients with
similar conditions. This is because of the difference in the skill levels, effort,
basic knowledge, dedication, and will of the treatment provider. Thus, execution
of the treatment is an art. Physiotherapy is a combination of science and
art. Science is the body and art is the soul of physiotherapy. In this light,
we can say that physiotherapy is also subjective in nature. This combination
of ‘objectivity’ and ‘subjectivity’ gives a unique flavor to this profession.
Subjectivity, rather than becoming a negative trait, blossoms like a flower
when a physiotherapist is treating a patient.
A lot has been written on physiotherapeutic management of a patient suffering
from hemiplegia/paresis by developed nations. But, as a matter of fact, the
requirement of the patient as well as availability of resources does differ from
nation to nation. Our nation too has a different approach to disease, disability
and impairment and hence, subtle changes are mandatory and strongly advocated
in approach towards the condition and its treatment.
Hemiplegia is not just a neurological or a musculoskeletal dysfunction,
but rather is a dysfunction of the personality as a whole. It is extremely difficult
for the patient to keep his physical disability and its psychological impact
separate. This psychosocial impact on the patient’s life spreads its fangs towards
their respective family members too, and they become victims of the situation.
Thus, there arose a need to address the issue of physiotherapeutic management
of hemiplegia in a new light, focusing on needs of our society.
This treatment guide would be beneficial to all the physiotherapy students
and fresh graduates who want to make difference in the lives of the patients
by doing justice to their profession. This book can become a useful guide
for a practicing physiotherapist (undergraduate/postgraduate) working in private
setup, government setup, hospitals or as a homecare therapist, for a quick
viii A Practical Guide to Hemiplegia Treatment
reference and progression of therapy with logical reasoning, as assessment

and treatment parts go hand in hand.
For the ease of readers, an attempt has been made to cover all major topics
in a nutshell in simple, lucid language with an optimum flow and continuity.
The book is divided into various topics ranging from Basic Anatomy and
physiology of brain, development of nervous system, to clinical diagnosis,
symptomology and detailed assessment. It also deals with essentials of
Rehabilitation medicine and approach to treatment. For the ease of quick
reference, various exercises and treatment techniques are divided into lying,
sitting and standing positions. Topics of orofacial rehabilitation, perception,
orthotics, and management of complications are also dealt with. It concludes
with homecare program.
I sincerely hope that this book will throw light on the dark path of disability
and will help in bringing about improvement in the quality of life of individuals
suffering from hemiplegia.
Ipsit Brahmachari
Acknowledgments
Any stream of knowledge is not a discrete entity but rather is a perennial
flow which flows from teachers to students over centuries. To claim any creation
to be ‘self-owned’ is erroneous, as present-day creation has its roots in the
soil of yesteryears. In bringing out this compilation in the form of a book,
I have been highly motivated and influenced by many persons and events,
both known and unknown to my conscious mind. Several texts have been
instrumental in teaching us the nuances of physiotherapy. To mention a few,
Principles of Exercise Therapy by Dena Gardiner, Hemiplegia by Berta Bobath,
PNF in Practice by Adler, Beckers and Buck and, Physical Rehabilitation by
O’ Sullivan, Cash’s Textbook of Neurology, and Steps to Follow by Patricia
Davies.
I would like to thank all my teachers who have always been guiding force
in my life. Some teachers of physiotherapy deserve a special mention;
Dr Mina Desai, Dr Sarala Bhatt, Dr Anjali Bhise, Dr Yagna Shukla, and
Dr Dilip Patel. I extend my thanks to Dr Roshan Vania and Dr Preeti Shah
for initiating me into the teaching of Bobath techniques and neurodevelopment
techniques. I sincerely thank Dr Maya Nanavati, an Occupational Therapist
for teaching her valuable hands-on skills. I thank Dr Sudhir Shah, a master
Neurophysician and a great scholar who extended support, believed in me
and allowed me to treat his patients. I thank Dr Amit Bhatt for being always
supportive. I extend my thanks to Dr Dhiren Ganjwala (Orthopedic Surgeon)
for contributing chapter on Orthopedic Management of Stroke.
I thank my staff and colleagues at Marg Physiotherapy and Rehabilitation
Clinic, especially Dr Darshan Rana for photography, coordination, and tolerating
me, and Dr Vikas Dhimmar for typing. I also thank Dr Jugal Sherdiwala
for his support. I take this opportunity to thank my family Dr Urvi, my wife,
Jalormi, my daughter and my parents as pillars of my strength.
I thank Shri Jitendar P Vij (Group Chairman), Mr Ankit Vij (Group President),
Mr Tarun Duneja (Director–Publishing), Mr Sharad (Gujarat branch) and all
the staff of M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India,
for bringing out this book and believing in me.
Last but not least, I thank all my patients who have lovingly cooperated
in this process.
Contents
1. 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 53
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
xii A Practical Guide to Hemiplegia Treatment
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 153
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
Contents xiii
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 224
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
xiv A Practical Guide to Hemiplegia Treatment
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 298
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 304
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
Contents xv
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 352
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
xvi A Practical Guide to Hemiplegia Treatment
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 423
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 index 478
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
Bibliography 493
Index 499
Basic Anatomy and Physiology of Human Brain 1
C H A P T E R
1
Basic Anatomy and Physiology
of Human Brain
ANATOMY OF THE HEAD

The human nervous system consists of the Central Nervous System (CNS)
and Peripheral Nervous System (PNS). The former consists of the brain and
spinal cord, while the latter composes the nerves extending to and from the
brain and spinal cord. The primary functions of the nervous system are to
monitor, integrate (process) and respond to information inside and outside
the body. The brain consists of soft, delicate, nonreplaceable neural tissue.
It is supported and protected by the surrounding skin, skull, meninges and
cerebrospinal fluid.
Skin
The skin constitutes a protective barrier against physical damage of underlying
tissues, invasion of hazardous chemical and bacterial substances and, through
the activity of its sweat glands and blood vessels, it helps to maintain the
body at a constant temperature. Together with the sweat and oil glands, hairs
and nails, it forms a set of organs called the integumentary system. The skin
consists of an outer, protective layer, the epidermis and an inner layer, the
dermis. While the top layer of the epidermis, the stratum corneum, consists
of dead cells, the dermis is composed of vascularized fibrous connective tissue.
The subcutaneous tissue, located underneath the skin, is primarily composed
of adipose tissue (fat) (Figure 1.1).
2 A Practical Guide to Hemiplegia Treatment
FIGURE 1.1: Layers of skin
Skull
Depending on their shape, bones are classified as long, short, flat or irregular.
Bones of different types contain different proportions of the two types of
osseous tissue: compact and spongy bone. While the former has a smooth
structure, the latter is composed of small needle-like or flat pieces of bone
called trabeculae, which form a network filled with red or yellow bone marrow.
Most skull bones are flat and consist of two parallel compact bone surfaces,
with a layer of spongy bone sandwiched in between. The spongy bone layer
of flat bones (the diploe) predominantly contains red bone marrow and hence,
has a high concentration of blood.
The skull is a highly complex structure consisting of 22 bones altogether.
These can be divided into two sets, the cranial bones (or cranium) and the
facial bones. While the latter form the framework of the face, the cranial
bones form the cranial cavity that encloses and protects the brain. All bones
of the adult skull are firmly connected by sutures. Figure 1.2 shows the most
important bones of the skull. The frontal bone forms the forehead and contains
the frontal sinuses, which are air filled cells within the bone. Most superior
and lateral aspects of the skull are formed by the parietal bones while the
occipital bone forms the posterior aspects. The base of the occipital bone
FIGURE 1.2: Bones of the skull
contains the foramen magnum, which is a large hole allowing the inferior
part of the brain to connect to the spinal cord. The remaining bones of the
cranium are the temporal, sphenoid and ethmoid bones.
Meninges
The meninges are three connective tissue membranes enclosing the brain and
the spinal cord. Their functions are to protect the CNS and blood vessels,
enclose the venous sinuses, retain the cerebrospinal fluid, and form partitions
within the skull. The outermost meninx is the dura mater, which encloses
the arachnoid mater and the innermost pia mater (Figure 1.3).
FIGURE 1.3: Meninges

Cerebrospinal Fluid
Cerebrospinal Fluid (CSF) is a watery liquid similar in composition to blood
plasma. It is formed in the choroid plexuses and circulates through the ventricles
into the subarachnoid space, where it is returned to the dural venous sinuses
by the arachnoid villi. The prime purpose of the CSF is to support and cushion
the brain and help nourish it. Figure 1.4 illustrates the flow of CSF through
the central nervous system.
FIGURE 1.4: Cerebrospinal fluid
THE MAJOR REGIONS OF THE BRAIN AND

THEIR FUNCTIONS
The major regions of the brain are the cerebral hemispheres, diencephalon,
brainstem and cerebellum (Figure 1.5).
Cerebral Hemispheres
The cerebral hemispheres, located on the most superior part of the brain, are
separated by the longitudinal fissure. They make up approximately 83% of total
FIGURE 1.5: Major regions of the brain
FIGURE 1.6: Cerebral hemispheres
brain mass and are collectively referred to as the cerebrum. The cerebral cortex
constitutes a 2–4 mm thick gray matter surface layer and, because of its many
convolutions, accounts for about 40% of total brain mass (Figure 1.6).
 Gray matter is responsible for conscious behavior and contains three different
functional areas: the motor areas, sensory areas and association areas. Located
internally is the white matter.
 White matter is responsible for communication between cerebral areas and

between the cerebral cortex and lower regions of the CNS, as well as the
basal nuclei (or basal ganglia), involved in controlling muscular movement.
Diencephalon
The diencephalon is located centrally within the forebrain. It consists of the
thalamus, hypothalamus and epithalamus, which together enclose the third
ventricle.
The functions of the thalamus are:
 It acts as a grouping and relay station for sensory inputs ascending to the
sensory cortex and association areas.
 It also mediates motor activities, cortical arousal and memories.
The functions of the hypothalamus are:
 By controlling the autonomic (involuntary) nervous system, it is responsible
for maintaining the body’s homeostatic balance. Moreover, it forms a part
of the limbic system, the ‘emotional’ brain.
 The epithalamus consists of the pineal gland and the CSF producing choroid
plexus. Function of the pineal gland is not very well understood.
Brainstem
The brainstem is similarly structured as the spinal cord: it consists of gray
matter surrounded by white matter fiber tracts. Its major regions are the midbrain,
pons and medulla oblongata.
 The midbrain, which surrounds the cerebral aqueduct, provides fiber pathways
between higher and lower brain centers, contains visual and auditory reflex
and subcortical motor centers.
 The pons is mainly a conduction region, but its nuclei also contribute to
the regulation of respiration and cranial nerves.
 The medulla oblongata takes an important role as an autonomic reflex center
involved in maintaining body homeostasis. In particular, nuclei in the medulla
regulate respiratory rhythm, heart rate, blood pressure and several cranial
nerves. Moreover, it provides conduction pathways between the inferior
spinal cord and higher brain centers.
Cerebellum
The cerebellum, which is located dorsal to the pons and medulla, accounts
for about 11% of total brain mass. Like the cerebrum, it has a thin outer
cortex of gray matter, internal white matter and small, deeply situated, paired
masses (nuclei) of gray matter. The cerebellum processes impulses received

from the cerebral motor cortex, various brainstem nuclei and sensory receptors
in order to appropriately control skeletal muscle contraction, thus giving smooth
coordinated movements.
THE CEREBRAL CIRCULATORY SYSTEM

Blood Supply to the Brain
Figure 1.7 shows an overview of the arterial system supplying the brain. The
major arteries are the vertebral and internal carotid arteries. The two posterior
and single anterior communicating arteries form the circle of Willis, which
equalizes blood pressures in the brain’s anterior and posterior regions and
protects the brain from damage, should one of the arteries become occluded.
However, there is little communication between smaller arteries on the brain’s
surface. Hence, occlusion of these arteries usually results in localized tissue
damage.
Cerebral Hemodynamics
FIGURE 1.7: Cerebral circulatory system

The cardiac output is about 5 L/min of blood for a resting adult. Blood flow
to the brain is about 14% of this, or 700 ml/min. For any part of the body,
the blood flow can be calculated using the simple formula, blood pressure
multiplied by size of the arteries. Pressure in the arteries is generated by
the heart, which pumps blood from its left ventricle into the aorta. [Since
pressure was historically measured with a mercury manometer, the units are
commonly expressed in terms of (mm Hg), although the official SI unit is
the Pascal (Pa)]. Resistance arises from friction and is proportional to the
following expression (Vessel Diameter) divided by (Vessel Length). Also, the
viscosity of the blood increases the resistance and hence, it decreases the
blood flow rate in the arteries as well as the veins. The slow moving and
sluggish blood is a breeding ground for the increase in platelet activity and
hence, the chances of thrombosis increase. Blood flow is slowest in the small
vessels of the capillary bed, thus allowing time for the exchange of nutrients
and oxygen to surrounding tissue by diffusion through the capillary walls.
Approximately, 75% of total blood volume is ‘stored’ in the veins which,
because of their high capacity, act as reservoirs. Their walls distend and contract
in response to the amount of blood available in the circulation. However,
the function of cerebral veins, formed from sinuses in the dura mater, is somewhat
different from other veins of the body, as they are noncollapsible.
Autoregulation
Panerai (1998) describes autoregulation of blood flow in the cerebral vascular
bed as the mechanism by which cerebral blood flow (CBF) tends to remain
relatively constant despite changes in cerebral perfusion pressure (CPP). With
a constant metabolic demand, changes in CPP or arterial blood pressure, that
would increase or reduce CBF, are compensated by adjusting the vascular
resistance. This maintains a constant O2 supply and constant CBF. Therefore,
cerebral autoregulation allows the blood supply to the brain to match its metabolic
demand and also to protect cerebral vessels against excessive flow due to
arterial hypertension. Cerebral blood flow is autoregulated much better than
in almost any other organ. Even for arterial pressure variations between 50
and 150 mm Hg, CBF only changes by a few percent. This can be accomplished
because the arterial vessels are typically able to change their diameter about
4-fold, corresponding to a 256-fold change in blood flow. Only when the
brain is very active, is there an exception to the close matching of blood
flow to metabolism, which can raise up to 30–50% in the affected areas.
It is an aim of PET, functional MRI, near infrared spectroscopy (NIRS) and
possibly, near infrared imaging, to detect or image such localized changes

in cortical activity and associated blood flow.
THE NEONATAL BRAIN

The embryonic brain and spinal cord develop from the neural tube, which
is formed in the fourth week of pregnancy. The brain grows immensely in
both size and complexity, during pregnancy and even soon after birth. Because
a membranous skull restricts expansion, the forebrain is bent towards the
brainstem and the cerebral hemispheres almost completely envelop the
diencephalon and midbrain. Moreover, the spatial restrictions cause the cerebral
hemispheres to increase their surface area by becoming highly convoluted
such that about two-thirds of its surface is hidden in its folds. The skull bones
of the fetus and neonate are soft and the sutures are not yet fused. Hence,
the skull is very flexible and deforms under light pressure (Hirschowitz, 1988).
Compared to the adult, neonates have a smaller head size (6–12 cm in diameter),
thinner surface tissue, skull and CSF layers, lower scattering coefficients of
gray and white matter (due to lesser myelination in the case of white matter),
as well as, a comparatively small mismatch between the two.
Arterial and venous hemoglobin saturation values for the fetus in utero
are relatively low at 56% and 18% (Rooth, 1963), respectively, compared
to about 97% and 67% for adults. This is because there is a gradient in oxygen
concentration across the placenta which ensures diffusion of sufficient amounts
of oxygen from maternal blood into the fetal bloodstream. A higher oxygen
affinity of neonatal hemoglobin compensates for this. Over a period of about
6 months after delivery, the neonatal hemoglobin is gradually substituted by
the adult hemoglobin, which has a lower oxygen affinity.
Neurodevelopmental disorders in some preterm infants are due to either
hypoxic-ischemic damage to the periventricular white matter, or to intra-
ventricular hemorrhage and its consequences. The period of highest risk is
between 26 weeks and 32 weeks of gestation. In preterm infants, the majority
of hemorrhages occur into the ventricles and the surrounding white matter,
the periventricular region. Hypoxic-ischemic damage is caused by cerebral
under-perfusion, often combined with a global oxygen deficiency due to an
impaired lung function. It also affects the periventricular white matter, which
is thought to be a result of the following two effects:
1. Increased vulnerability due to high metabolic demands at this phase of
the brain development.
2. The area is at a ‘watershed’ of perfusion from the territories of the posterior
and middle cerebral arteries.
Enduring neurodevelopmental disorders can lead to diminished neurological

function in later life, and in particular spasticity, since motor fibers run through
this region of the white matter. Given the potential of the premature infant’s
developing brain to repair some damage, spasticity is often restricted to stiff
limbs and/or subtle learning disabilities. Cerebral damage in the mature infant
is most commonly a result of perinatal (‘birth’) asphyxia, leading initially
to cerebral edema (resulting in compressed ventricles and flattening of the
convolutions of the brain) and later to tissue necrosis (tissue death) and apoptosis
(cell suicide). The subcortical white matter, basal ganglia, cerebellum and
brainstem are the areas predominantly affected, frequently leading to learning
disabilities or global developmental delay and cerebral palsy.
ASPECTS OF NEUROANATOMY AND

PHYSIOLOGY
The Nervous System as a Basic Unit of a Living Being
The nervous system is the basic unit which is used by the living creature
in order to be able to react to its environment. The more complex the creature,
the more complicated is its nervous system and the more versatile are its
reactions. The system is concerned with the physical (sensory, motor and
autonomic), intellectual and emotional activities and, in consequence, any
disorder may involve any one or all three of these major functions.
Neuron
The nervous system is composed of an enormous number of neurons, connected
together and following certain pathways, in order to make functional activity
possible. The neuron is the basic unit of the nervous system and comprises
of the nerve cell and its processes. Each neuron has a cell body and two
types of processes, dendrites and axons. Each ramus carries motor, sensory
and autonomic fibers and the sympathetic ganglion communicates with those
above and below it in level and also sends fibers to the visceral contents.
The corticospinal path represents the pyramidal system and other paths may
be considered to be extrapyramidal.
The Synapse
This is the term used to define the area where the process of one neuron
links with another. The synapse is the point of contiguity but not of continuity.
Synapses may occur between the terminal parts of an axon and the dendrites
of another cell or with the cell body. The number of synaptic areas may be
very vast in any one neuron. The synapse enables impulses from one neuron
to be transmitted to another neuron by virtue of chemical changes taking
place which bring about an alteration in membrane potential of receiving neuron.
Synapses have certain properties which are of importance. Some of the more
important ones are:
 Synaptic delay: When an impulse reaches a synapse, there is a brief time
lag before a response occurs in the recipient neuron. Consequently, conduction
along a chain of neurons is slower than along one single neuron. Thus,
monosynaptic pathways conduct more rapidly than polysynaptic routes.
 One way conduction: Synapses permit conduction of impulses in one
direction only, i.e. from the presynaptic to the postsynaptic neuron.
 Vulnerability: Synapses are very sensitive to anoxia and to the effects
of drugs. Polysynaptic pathways are very susceptible to anesthesia.
 Summation: The effect of impulses arriving at a synapse can be added
to by other impulses. For instance, the effect of impulses could be subliminal
(insufficient to bring about adequate chemical change for depolarization
of the postsynaptic neuron). If, however, another spate of impulses arrives
before the effect of the previous one has subsided, then the two effects
may complement each other and the total change is sufficient to cause
depolarization. Such a phenomenon is called summation. There are two
types of summations:
 One is dependent upon the time factor known as temporal summation and
 Other is called spatial summation, which is the result of the adding together
of impulses from different neurons, which converge upon the postsynaptic
neuron and bring about the depolarization of its membrane.
 Fatigue: The synapse is thought to be the site of fatigue in nerve conductivity.
 Inhibition: Certain neurons have an inhibitory effect upon the postsynaptic
neuron, possibly because they use a different chemical mediator. Thus, the
effect of these neurons would be to discourage depolarization of the post-
synaptic cell membrane and would be antagonistic to influences exerted
by excitatory neurons. These effects can summate in the same way as the
excitatory effects. Many interneurons have an inhibitory effect.
 Post-tetanic potentiation: This occurs across synapses, which have been
subjected to prolonged and repeated activity. The threshold of stimulation
of these junctions is thought to be lowered making transmission across
it more easily brought about, for a period of several hours. Facilitation
of transmission is said to occur and is an elementary form of learning
and also forms an important part in the approach to physical treatment
of patients with neurological disorders.
 Supporting tissue: Neurons are delicate, highly specialized structures and

require support and protection. This is afforded to them in the nervous system
by specialized connective tissue called neuroglia. If neurons are damaged
and destroyed, their place is filled by proliferation of neuroglial material.
The axons are surrounded by a fatty sheath called myelin, which has an
important effect on the conduction of impulses. Because of this sheath, bundles
of axons give a whitish appearance and form the white matter of the central
nervous system.
When the axon and its myelin sheath leave the central nervous system, they
become surrounded by a membrane called the neurilemma. This is of vital
importance and it should be noted that the neurilemma is absent around the
fibers of the brain and spinal cord, whereas it is present, as soon as they leave
these areas.
Nerve fibers which are surrounded by the neurilemma may regenerate if
they are destroyed. Hence, destruction of fibers in a peripheral nerve does
not necessarily mean permanent loss of function, whereas destruction of the
fibers in the central nervous system will mean permanent loss of function
of those fibers. It should also be noted that the nerve cell is resilient to injury
and has recuperative powers but, if it dies, it is incapable of being replaced.
Thus, destruction of cell bodies means permanent loss of function.
FIGURE 1.8: Areas of brain

TABLE Brain structure, function and associated symptoms

1.1
Brain structure Functions Associated signs and
symptoms
Cerebral Cortex The outermost layer of

the cerebral hemisphere
which is composed of
gray matter. Cortices are
asymmetrical. Both
hemispheres are able to
analyze sensory data,
perform memory
functions, learn new
information, form
thoughts and make
decisions
Ventral view
(From bottom)
Left Hemisphere Sequential analysis:

systematic, logical inter-
pretation of information.
Interpretation and pro-
duction of symbolic
information: language,
mathematics, abstrac-
tion and reasoning.
Memory stored in a
language format
Right Hemisphere Holistic functioning:

processing multisensory
input simultaneously to
provide “holistic” picture
of one’s environment.
Visual spatial skills.
Holistic functions such as
dancing and gymnastics
are coordinated by the
right hemisphere.
Memory is stored in
auditory, visual and
spatial modalities
Contd...
Contd...

symptoms
Corpus Callosum Connects right and left  Damage to the
hemisphere to allow for corpus callosum may
communication between result in “Split Brain”
the hemispheres. Forms syndrome
roof of the lateral and
third ventricles
Frontal Lobe Cognition and memory.  Impairment of recent

Prefrontal area: The memory, inattentive-
ability to concentrate ness, inability to con-
and attend elaboration centrate, behavior
of thought. The “Gate- disorders, difficulty in
keeper ”; (judgment, learning new infor-
inhibition). Personality mation. Lack of inhi-
and emotional traits bition (inappropriate
social and/or sexual
Movement: Motor behavior). Emotional
Ventral view Cortex (Brodmann’s): lability.
(From bottom) voluntary motor activity  Contralateral plegia,
paresis
Premotor cortex: Storage  E x p r es s i ve / m o t o r
of motor patterns and aphasia
voluntary activities
Language: Motor speech
Side view
Parietal Lobe
Processing of sensory  Inability to discrimi-
input, sensory discriminate between
nation sensory stimuli
 Inability to locate and
Body orientation recognize parts of the
body (Neglect)
Primary/secondary  Severe injury: Inabi-
somatic area lity to recognize self
Contd...
Contd...

symptoms
 Disorientation of
environment space
 Inability to write
Occipital Lobe Primary visual reception  Primary visual cortex:

area Loss of vision of
opposite field
Primary visual associa-  Visual association
tion area: Allows for cortex: Loss of
visual interpretation ability to recognize
object seen in
opposite field of
vision, “flash of
light”, “stars”
Temporal Lobe Auditory receptive area  Hearing deficits

and association areas  Agitation, irritability,
childish behavior
Expressed behavior  Receptive/sensory
aphasia
Language: Receptive
speech
Memory: Information
retrieval
Limbic System Olfactory pathways:  Loss of sense of
Amygdala and their smell
different pathways  Agitation, loss of
Hippocampi and their control of emotion
different pathways  Loss of recent
memory
Limbic lobes: Sex, rage,
fear, emotions. Integra-
tion of recent memory,
biological rhythms
Hypothalamus
Contd...
Contd...

symptoms
Basal Ganglia Subcortical gray matter  Movement disorders:

nuclei. Processing link chorea, tremors at
between thalamus and rest and with initia-
motor cortex. Initiation tion of movement,
and direction of volun- abnormal increase in
tary movement. Balance muscle tone, diffi-
(inhibitory), postural culty initiating move-
reflexes ment
 Parkinson’s symptoms
Part of extrapyramidal
system: Regulation of
automatic movement
The Development of Nervous System 17
C H A P T E R
2
The Development of
Nervous System
INTRODUCTION
The dynamic process of motor structuration in the early stages of infantile
development appears to be essentially an interweaving of various patterns
which appear and disappear and overlap with each other in their mutual
interacting and modulating influence with an orderly integration in the
developmental process.
In order to acquire the progressive refinement of selective motor behavior,
the massive, gross functional units of reflex patterns have to be broken down
into small polyvalent units available for reconstruction of other new patterns
for the performance of normal movements (Milani Comperatti, 1994).
DEVELOPMENT OF MOVEMENT, POSTURE

AND DEVELOPMENTAL NEUROLOGY
Movement, in its basic performance, is a series of primitive reflex activity.
Learning of movements is “entirely dependent on sensory experiences.”
Sensory input initiates and guides the motor output.
As the central nervous system (CNS) matures and unfolds, the normal child
gradually changes, modifies, integrates, conditions and partially inhibits various
statokinetic reflex activity to form automatic postural reflex mechanism for:
 Regulation of body tone
 Maintenance of balance
 Performance of skillful, coordinated, goal oriented movements.
The evolution of our erect posture, narrow base and freedom of upper
extremities from the function of support to prehension, demands a fully developed
and highly complex postural control mechanism (Bobath).
Body tone: The smooth performance of the movement demands normal tones
of the entire neuromuscular apparatus. Normal tone permits the movement
to flow smoothly without interruption, the limb feels light and when placed
in a position, it will momentarily hold before returning to its original resting
place. The normal tone must be high enough to maintain us upright against
gravity but not too high to impede the movement.
Reciprocal innervation and inhibition for the agonists to perform smooth
flow of the movement, the antagonist groups instantly adapts and adjust to
their increase in length.
The agonists, antagonists, synergists and fixators come into play in exact
well-timed, coordinated order and in precise gradation of contractions for
maintenance of balance, posture and movement performance, hence voluntary
movements are performed totally against the background of the automatic
postural adjustments which are beyond our conscious level and are under
subcortical influence. The automatic postural sets precede the voluntary
activity. Postural adjustments occur not only as a result of the sensory
feedback in respect to unexpected perturbations but also as a result of
feed forward in anticipation of expected stimuli which are self-generated
perturbations. (For example, When an examiner is going to touch a painful
area in the subject).
Voluntary movements have these components:
 Volition
 Purpose
 Awareness
 Effort.
Posture is movement arrested. It is the attitude adopted by the body at
rest or in movement and is maintained by neuromuscular activity of muscle
groups, for maintenance of balance and performance of various skillful functional
movements.
Basic essential for good posture and midline alignment is the stability and
mobility of the trunk, because the trunk is the basis for head control, limb
functions. Head, neck and limbs are the extensions of the trunk. If one loses
trunk control, head and limb movements are lost. The statokinetic patterns
of posture interact and reinforce each other for:
 Weight bearing
 Maintenance of balance and equilibrium
 Postural adjustments into gravity: Postural adaptation to gravity and against gravity
 Head neck orientation and postural adjustment of the head to the shift of
the body
 Midline orientation: It is the point of references for movement over a base

of support; one should be able to stabilize in midline
 To move away and back to midline and to cross over the midline.
Vestibular system plays a critical role in:
 Regulation of the body tone
 Accurate orientation of the body in space
 Development of visuospatial skills.
CNS Functions
Human brain is the most complex system generating both simple and complex
behavioral patterns. Brain is who we are, essence of humanity (A. N. A 1998).
GALEN centuries back stated in his writing, describing the brain to be the
seat of intelligence; movements and sensation. WALSH (1948) stressed that
the CNS functions as a whole as the integrated sensory motor unit.
Bobath (1970) said that the CNS is an organ of reaction rather than action,
reacting to various sensory stimuli converting upon it from within and without
acting as “coordinating unit” to the multitude of incoming sensory stimuli
to produce integrated motor responses adequate to the demands of the
environment.
In the modern day thinking, CNS is looked upon as a system composed
of billions of nerve cells which by virtues of their self-organization, integration,
interaction and coordination form a neural network giving rise to how we think,
act, decide, remember, perceive, learn, adapt and develop (Scott Kelso, 1995).
Clinical and experimental evidence indicates that the cortex plays critical
role in processing, execution and programming of the normal voluntary motor
control on the basis of sensory input signals. Movements are reflex automatic
and volitional.
In situation, when speed is paramount to trajectory and accuracy of the
movement, the brain abstains from the feedback comparison of the actual
with the desired action, like withdrawing finger from a hot burning object
and these movements are executed at spinal or subcortical level.
Central nervous system is constantly seeking input for output, for it is
continuously perceiving, intending, anticipating, learning and adapting to the
environment to form and develop dynamic patterns of function and human
behavior (Scott Kelso, 1995).
We are already living in the 21st century but, unfortunately there are therapists
who are neglecting the input system and consider only the output of the CNS
to improve the motor control or the joint ranges missing out on the CNS
function.
Perception signifies our ability to learn, adapt and adjust to the environment.
It refers to the activity occurring in the secondary and tertiary sensory association
areas of the parietal lobes, which integrates information such as memory, context
and experience.
Perception is defined as the ability to interpret various incoming sensory
messages so that sensation has meaning. Perception memory and language
are described as cognitive skills and are integrated in higher centers in CNS.
Affronter and Striker define perception as: “Understanding how the CNS
transforms, analyzes, promptly organizes, integrates and structure the various
sensory information received from the environment, there is a constant interaction
between the individual and environment. Interaction means to be in touch
with or contact with, to be in touch with is ‘to feel’. In this ‘Key Factor’
we cannot decide, if we touch the environment or environment touches us.”
Newborn baby, at the age of three months, first touches various objects
and manipulates, this is through Tactokinesthetic channel. After that, the following
develops:
 Eye objects contact through visual channel
 Turning his head in direction of sound through auditory channel.
As we are constantly in touch with one environment, the primary channel
of learning is tactokinesthetic. Perceptual processes must have absolutely intact
highly developed sensory feedback system. Minutest flaw causes disturbances
in perceptual processes as is observed in CNS lesions. Voluntary movement
is dependent on the perception of superficial, deep and proprioception sensation
and motor power, coordination and tone. Grossly, functions of CNS are:
 Regulation and distribution of muscle tone throughout the body
 Maintenance of posture and balance at rest and in movement
 Orientation of body in space
 Inhibitory control over the undesired movements, to perform goal oriented,
selective, skillful movements, reciprocal inhibition and innervation
 Inhibition of undesired movements or activity or overactivity is one of
the most important roles of the CNS as a result of the ratio of the inhibitory
fibers are far greater in CNS as compared to excitatory fibers in the subcortical
and spinal pathways.
Kokte (1978) has stated that every new activity we learn, “We are surrounded
by wall of inhibition.” Inhibition is active at every level of CNS, at spinal
levels, it manifests in larger synergic patterns of flexion and extension (flexor
withdrawal, extensor thrust). At higher level, inhibition becomes more and
more complex, leading to fractionation of the original primitive patterns for
the performance of selective motor activity in various combination and skillful,
prehensile motor activity. Inhibition is a balance of activity between inhibitory

and excitatory fibers and plays important role in the gradation of the movement
controlling range, speed and direction of the movement.
Bobath states, “I always think inhibition is a sculpting process, chisels away
at the diffuse and rather amorphous mass of excitatory action and gives a
more specific form to the neural performance at the every stage of synaptic
relay. Removal of inhibition causes excitation by process that is called
disinhibition.”
The development of the nervous system from conception to maturity is
a complex and fascinating process. Development is a concept which implies
both growth and maturation. Growth is not just an increase in size, but the
development of increasingly more complex interconnections within the brain.
The nervous system arises from the neural plate which folds to form the neural
tube about the 3rd to 4th week after conception (O’ Reilly and Gardner, 1977).
The development of a series of flexures then occurs with the different regions
of the brain and cerebral hemispheres are visible as paired vesicles at the
end of the 5th week.
At birth, the human brain is very well developed; a complex and relatively
larger organ than any other animal. The relative size of the brain, 12% of
the body mass, is also much larger than at maturity, when it is 2%.
NEONATAL REFLEXES
The neonatal reflexes are responses which can be reproduced readily after
a particular stimulus. There are also a number of responses which are patterns
of movement regularly seen in the newborn period but which are not elicited
after every stimulus.
The neonatal reflexes must be looked at with some circumspection. They
are present even in babies with severe abnormality of the brain or even absence
of the cortex as in anencephaly. Abnormal reflexes, with asymmetry, or absent
or persistent reflexes should be considered significant. Stereotyped responses
are particularly significant (Touwen, 1976).
Moro Reflex
The best way to elicit reflex is by the ‘head drop’ method. The baby is held
in supine supported behind the chest and head, the head is allowed to drop about
10°. The arms extend and then flex. The legs also extend and then flex.
The Moro reflex is fully developed in the term infant. It gradually disappears
over the first 3–4 months of life, first in the legs, then in the arms.
Absence of the Moro response may signify severe depression of the CNS
or marked hypotonia. Persistence of the Moro, particularly an excessive response,
occurs in the absence of inhibition. The Moro reflex is probably a vestibular
response (Prechtl, 1956), although proprioceptive responses from the cervical
vertebrae have also been considered as mediators of the response.
The Asymmetric Tonic Neck Response (ATNR)

A normal posture seen at rest, it may be imposed by the examiner turning
the head, between 2 months and 4 months. A strongly imposable reflex after
6 months, or an obligatory response at any age, is the evidence of significant
motor handicap.
Palmar Grasp
The infant should be supine with head in the midline; an index finger is
placed in the palm of each hand and the palmar surface pressed. A normal
response is strong sustained flexion of the fingers for several seconds.
Plantar Grasp
This can be elicited by stimulating the roof of the toes when active flexion
will occur.
Rooting Reflex
While the infant supine, head in the midline, each corner of the mouth is
stimulated by stroking laterally, the head turns, mouth open and grasps, the
lips may curl to the stimulated side.
Sucking Reflex
The index finger is placed in the baby’s mouth, pad up and the sucking action
noted. A normal reaction is a sustained strong sucking action.
Walking Reflex
The baby is held in a standing position with the chin and head supported
by one’s fingers; a normal response is discernible steps with knee and hip
flexion and a step on each side. The walking response is usually lost within
4 weeks or so of birth and supporting reactions of the legs do not reappear
in the infant for several months. Passive extension of the head results in
reinforcement of this reflex (Mac Keith, 1964).
The asymmetric tonic neck response (ATNR) is a posture seen frequently

in normal babies between 2 months and 5 months. The head is turned to
the side, the arm and leg on that side are extended and on the opposite side,
they are flexed. This is not an obligatory response except in an abnormal
baby, when its persistence and reproducibility indicates pathology.
The disappearance of neonatal reflexes during development occurs as the
nervous system matures and the neural mechanisms merge into more complex
mechanisms. It is for this reason that infantile response reappears after
serious brain damage or in degenerative conditions. It is also for this reason
that the reflexes persist in babies who have sustained damage to the nervous
system at birth. Although, plasticity in the CNS allows for remodeling of
some of the damaged brain, the position of the damage is all-important
in the final outcome.
Three types of neural mechanisms, as defined by Touwen (1976), can be
distinguished:
1. Primary or basic neural mechanisms, e.g. for visual or acoustic perception
and mechanisms for generating adequate muscle tone.
2. Mechanisms which merge into larger and more complex mechanisms or
seemingly disappear completely to reappear in another form in a later stage
of development, e.g. stepping movements and voluntary walking patterns.
3. Mechanisms which mature more or less independently and become linked
together at a particular moment. This process results in differentiated motor
patterns, e.g. the development of voluntary grasp ending with a pincer grasp
and the development of independent sitting, standing and walking.
DISCUSSION OF DEVELOPMENTAL SEQUENCES

AND ITS IMPORTANCE IN TREATMENT PLANNING
OF THE PATIENT
Mature movements are complex permutations of the basic flexion and extension
synergies. Until the patient can mix flexion and extension components of
movements, only mass patterns can be produced. The ability to stabilize the
trunk and proximal part of limbs while allowing distal parts to move is important
where skilled activity is concerned and cerebellar activity is very important
to this. Equally well, the ability to retain a fixed distal extremity while the
proximal segments and trunk move over it is also essential. Much of the
patient’s development progress is related to the ability to produce these two
varieties of movement, not only as distinct entities, but going on at the same
time.
The Mixture of Flexion and Extension Components

Example 1
When the sitting position is considered:
This requires extension of the vertebral column, but flexion of the hips and
knees. If it is impossible to extend the column unless a total extension pattern
is used, then the patient is unable to maintain a sitting position.
Example 2
When the lower limbs are considered in the walking synergies:
When the hip and knee flex, the lower limb also abducts and may laterally
rotated and the foot dorsiflexes. However, to walk forward we require flexing
the hip and knee while adducting the limb. This is followed by extending
the knee while dorsiflexing the foot. Here, alone are some interesting synergies.
The leg then prepares to take weight it extends at the knee and hip and abducts
to prevent a Trendelenburg sign (drop of the pelvis on the nonweight-bearing
side). Another mixture of synergy is when the abductors of the weight-bearing
limb are working to prevent the pelvis from dropping on the nonweight-bearing
side. When the abductors are not working, the pelvis drops into adduction
on that side, causing a compensatory lurch of the trunk. This is called a
Trendelenburg sign.
The push-off requires more extension of the hip, flexion of the knee and
plantar flexion of the foot. This is a very complex series of synergies. The
ability is not immediately available. The patient who has recently started walking,
flexes and abducts his hip. Only later after proper training, does he keep
it adducted as the leg comes forwards.
Proximal Fixation and Distal Freedom and Vice Versa

Example 1
A simple example may be seen when we consider someone in prone lying.
When he is able to take weight on one elbow while manipulating an object
with the other hand, he is demonstrating distal fixation of the supporting limb
with the trunk free to move over it, while the free limb is moving distally
against the proximal support of the steady trunk.
Example 2
A more complex example of the same thing occurs with the much more mature
pattern of writing. Here, the supporting arm is offering distal stability to the
trunk which is free to move over it. The hand which is putting pen to paper
is working freely with a more proximal area of stability in the forearm. However,
the forearm must also be partly free to move for each word and so movement
at the shoulder has to occur. The shoulder is functioning as a stable and mobile
structure at one and the same time against the stable background of the trunk
which, in turn, is free to move over the other, or supporting limb. This is
a very complex synergy. Little wonder that we cannot write at birth!
Many learning processes depend upon the ability to move. We require
movement to be able to explore our environment and unless this is possible,
our mental processes cannot develop normally. Head control is essential to
movement, but is also essential for the ability to make maximum use of the
sense of sight. If we cannot control our head position, it is difficult to gain
control over our eye activities. The eyes need to have a stable base from
which to work. Eye movements are similar to limbs. They can remain stable
while the head moves, or they can move while the head stays still, or the
two activities may go on at once, none of this is possible if head control
is absent. Assessment of spatial relationship depends upon movement. The
relationship between hands and eyes depends upon the ability to move and
explore, and the perception of depth, space, height, size and shape have all
to be learned by experience dependent upon movements of different area of
the body. Balance activities basically start by the balance of the head upon
the shoulders in prone lying. Progression is then made by balancing the shoulders
over the elbows which offers a forward support in prone lying. In sitting,
the body is at first inclined forward so that head balance on the shoulders
is still an extension activity and the arms are in a supporting forward position,
but with extended elbows. Later, the ability to balance with the arms supporting
sideways develops and much later the arms may support by being placed
behind as when sitting in a backward leaning position. This requires flexor
activity the head and neck to maintain the balance of the head on the shoulders.
Before the patient is taught to sit with the backward support training for the
rotator ability of the trunk should be done, as it is a precursor to more skillful
balance activities. Proper balance is said to be gained when upper limbs can
carry out skilled activities, while the legs and trunk are dealing with the
maintenance of equilibrium. The development of motor skills is not complete
until the hands can be used in prehensile activities and much work has been
done by various authors on the developments of prehension. The hand activities

are inclined to develop from ulnar to radial side. The grasp and release activities
of the early stages in development appear to commence with activity of the
little finger and radiate out towards the thumb. Gradually, the radial aspect
of the hand becomes more dominant and eventually the pincer grasp between
thumb and index finger develops while the ulnar side of the hand takes up
a more stabilizing function. Much more mature is the ‘dynamic tripod’ posture
described by Wynn Parry in 1966 and explained by Rosen Bloom and Horton
(1971). Here the thumb, index and middle fingers are used as a threesome
to give fine coordinate movements of the hand. The classic example of the
use of this tripod is in writing although it may be seen in other functional
activities.
The process of integrating certain reflex mechanisms involved in movement
occurs over a period of time and eventually makes controlled purposeful
movement possible. The control develops in a cephalocaudal direction. It is
closely linked with perception of body image, intellectual and social behavior
and, although it is not dependent upon environment factors, these may influence
the rate at which perfection develops. Motor development starts with control
of the head position in prone, with the upper limbs most able to take weight
in a forward or elbow support position. Later development include rolling
and supported sitting with the weight supported forwards on the hands at
first, and later at the sides and even later behind. Body rotation begins to
be perfected as rolling occurs and limb rotation follows trunk rotation as rule.
Movements at first follow primitive patterns of synergy, but later the ability
to combine flexion-extension patterns to give more complexity of movement
should develop. Ultimate maturity of movement is reached when the hands
are totally free from an obligation to balance mechanisms, so that they can
be freely developed as skillful tools and used in conjunction with visual and
other sensory feedback mechanisms.
The patient is always made to experience the normal movement patterns
in the actual and factual environment before placing the demand on the
developing brain so that the patient will know what exactly to expect while
performing a certain task.
Example 3
To sit in a balanced manner, the patient needs to flex at the hips and extend
at the trunk. He needs head control and the ability to support himself forwards
on his hands. These are minimum requirement. He is prepared for this naturally
by the early development of head control; the elbow and hand support prone
position and by lying on his back working out on the trunk flexors. The
therapist helps him by propping him into a sitting position so that he experiences
it prior to achieving it. Help in this manner makes him experiment and he
tries to balance when he is put into sitting and in fact learns to do so.
In the meantime, his rolling and rotatory activities are developing. The
patient gradually develops the ability to get into sitting after he has learned
to balance in that position.
THE CLINICAL VALUE OF KNOWLEDGE OF

DEVELOPMENTAL SEQUENCE
When working with handicapped children, hemiplegic patients and, in particular,
with the very young, it is easy to see that this information is exceedingly
valuable. When treating babies with movement defects, it is important to start
as early as possible and to bear in mind the normal sequence of development
so that one can, as far as possible, channel the child’s reactions along suitable
lines and encourage step by step progress without leaving gaps which may
lead to abnormality. The earlier the abnormal child is given help the more
successful is the treatment likely to be. It is much more difficult to correct
abnormal habits than it is to prevent them from occurring. The child’s nervous
system is very malleable and able to adapt very readily. Consequently, it can
be most easily influenced before it is fully matured. It is a great mistake
to wait until the child can consciously cooperate. By this time, irretrievable
abnormalities will have developed. The skilled physiotherapist is able to exploit
the knowledge of the nervous system to stimulate suitable responses in the
childe long before he is aware of cooperating.
However, many physiotherapists deal only with adults or, at least the greater
bulk of their patient load is adult. Where then does this knowledge have value?
The answer is simply that injury or disease to the control nervous system
frequently brings about demyelization of certain areas and may damage or
destroy the nervous pathways which have been used to control certain activities.
The patient frequently shows a regression of motor skills to a more primitive
level. Certain of the reflex mechanisms, which have hitherto been integrated
into mature movement patterns, may be partly released from cortical control
and may exert an excessive influence over the patient, dominating these
movement patterns into abnormality or even preventing them from occurring
at all. The patient will frequently show absence or disturbance of normal
equilibrium reactions, poverty of movement synergy, perception difficulties
and diminution of sensory discrimination. If the physiotherapist is going to
help the patient to make full use of such nervous connections as are left,
he is more likely to be successful if he has knowledge of the way in which

more skilled activities develop in the first place so that he can, to some extent,
simulate the conditions to facilitate redevelopment. The following example
illustrates this point.
A patient with neurological symptoms can often maintain a sitting position
but, on attempting to stand, he pulls himself up by placing his hands on
a rigid forward support or by pulling on a helper who is standing in from
of him. Frequently, the head is flexed forward or, conversely, it may be thrown
back so that the nose is pointing upward. In the first instance, the patient
is using the symmetrical tonic neck reflex pattern to aid him into standing,
and in the second, his legs are making use of the tonic labyrinthine effect.
Neither of these is acceptable as the patterns are those of total reflex synergy,
and balance in standing will never be achieved using these patterns. Such
a patient has his movement excessively influenced by the tonic reflex mechanisms
and requires training to modify them and to start early balance activities.
He requires help in receiving weight on to his arms in a forward position.
Such activities as elbow-support prone lying are suitable, progressing to hand-
support forward side sitting, leading to prone kneeling and hand-support forward
standing (standing but resting hands on a stool or low support in front of
him). He needs to feel the sensation of weight being received forwards instead
of pulling back. There are many other facets to this patient’s problems which
need attention, but the above example makes the point.
Many head injury case regress to an enormous degree and intellectual and
social abilities regress also. Motor training along developmental lines is
accompanied, in many cases, by a brightening of intellectual activities and
the beginning of social communication. The patient may never achieve behavior
patterns which are mature, but he is more likely to make balanced progress
if a development approach is used.
Clinical Aspects of Stroke: A Major Cause of Hemiplegia 29
C H A P T E R
3
Clinical Aspects of Stroke: A
Major Cause of Hemiplegia
INTRODUCTION
Strokes are, by far, the most common cause of neurological disability in the
adult population. They are responsible for about a quarter of all deaths in
the developed countries and account for much disability in the elderly. Of
patients who suffer a stroke, about a third will die; a third will survive but
with severe disability and the remainder will make a good recovery with
functional independence. The onset is usually sudden with maximum deficit
at the outset, so the shock to patients and relatives is extreme. Stroke or
the cerebrovascular accident is the major cause of the residual hemiplegia
in the population.
The 1990 global burden of disease (GBD) study provided the first global
estimate on the burden of 135 diseases and cerebrovascular diseases ranked
as the second leading cause of death after ischemic heart disease. Data on
causes of death from the 1990s have shown that cerebrovascular diseases
remain a leading cause of death. In 2001, it was estimated that cerebrovascular
diseases (stroke) accounted for 5.5 million deaths worldwide, equivalent to
9.6% of all deaths. Two-thirds of these deaths occurred in people living in
developing countries and 40% of the subjects were aged less than 70 years.
Additionally, cerebrovascular disease is the leading cause of disability in adults
and each year, millions of stroke survivors have to adapt to a life with restrictions
in activities of daily living as a consequence of cerebrovascular disease. Many
surviving stroke patients will often depend on other people’s continuous support
to survive. Cerebrovascular diseases can be prevented to a large extent and
providing an entry point for public health initiatives to reduce the burden
of stroke within a population.
DEFINITION
The term ‘stroke’ is synonymous with cerebrovascular accident or CVA and
is a purely clinical definition which, according to the World Health Organization,
can be defined as a ‘rapidly developed clinical sign of a focal disturbance
of cerebral function of presumed vascular origin and of more than 24 hours’
duration’. Included within this definition are most cases of cerebral infarction,
cerebral hemorrhage and subarachnoid hemorrhage but deliberately excluded
are those cases in which recovery occurs within 24 hours. These latter cases
are designated ‘transient ischemic attacks’ (TIA) and because they are often
a harbinger of completed stroke, they have received considerable attention
over the past two decades. According to the National Stroke Association:
 10% of stroke survivors recover almost completely
 25% recover with minor impairments
 40% experience moderate-to-severe impairments that require special care
 10% require care in a nursing home or other long-term facility
 15% die shortly after the stroke
 Approximately 14% of stroke survivors experience a second stroke in the
first year following a stroke.
TYPES OF STROKE
Ischemic
The most common cause of stroke is due to obstruction to one of the major
cerebral arteries (middle, posterior and anterior, in that order) or their smaller
perforating branches to deeper parts of the brain. Brainstem strokes, arising
from disease in the vertebral and basilar arteries, are less common. Some
70 to 75 percent of all strokes are due to occlusion, either as a result of
atheroma in the artery itself or secondary to emboli (small clots of blood)
being washed up from the heart or diseased neck vessels. The patient does
not usually lose consciousness but may complain of headache and symptoms
of hemiparesis and/or dysphasia develop rapidly. The hemiplegia is initially
flaccid but within a few days, this gives way to the typical spastic type. The
middle cerebral artery supplies most of the convexity of the cerebral hemisphere
and important deeper structures, so there is a dense contralateral hemiplegia
affecting the arm, face and leg. The optic radiation is often affected leading
to a contralateral homonymous hemianopia and there may be a cortical type
of sensory loss. Aphasia can be severe in left hemisphere lesions and there
may be neglect of the contralateral side. In right hemisphere lesions, parietal
damage can lead to visuospatial disturbances. If the main part of the middle
cerebral artery is not affected, but one of its distal branches is, then the symptoms
will be less extreme. Thrombotic cerebral infarction results from the
atherosclerotic obstruction of large cervical and cerebral arteries, with ischemia
in all or part of the territory of the occluded artery. This can be due to occlusion
at the site of the main atherosclerotic lesion or to embolism from this site
to more distal cerebral arteries.
Embolic cerebral infarction is due to embolism of a clot in the cerebral
arteries coming from other parts of the arterial system, for example, from
cardiac lesions, either at the site of the valves or of the heart cardiac cavities,
or due to rhythm disturbances with stasis of the blood, which allows clotting
within the heart as seen in atrial fibrillation. Lacunar cerebral infarctions are
small deep infarcts in the territory of small penetrating arteries, due to a local
disease of these vessels, mainly related to chronic hypertension. Several other
causes of cerebral infarction exist and are of great practical importance for
patient management.
Hemorrhagic
About 5 to 10 percent of strokes are caused due to hemorrhage into the deeper
parts of the brain. The patient is usually hypertensive, a condition which leads
to particular type of degeneration known as lipohyalinosis in the small penetrating
arteries of the brain. The arterial walls weaken and as a result small herniations
or microaneurysms develop. These may rupture and the resultant hematomas
may spread by splitting along planes of white matter to form a substantial
mass lesion. Hematomas usually occur in the deeper parts of the brain, often
involving the thalamus, lentiform nucleus and external capsule, less often the
cerebellum and the pons. They may rupture into the ventricular system and
this is often rapidly fatal. The onset is usually dramatic with severe headache,
vomiting and, in about 50 percent of cases, loss of consciousness. The normal
vascular autoregulation is lost in the vicinity of the hematoma and since the
lesion itself may have considerable mass, intracranial pressure often rises abruptly.
If the patient survives the initial ictus, then profound hemiplegic and hemisensory
signs may be elicited. A homonymous visual field defect may also be apparent.
The initial prognosis is grave but those who begin to recover often do surprisingly
well as the hematoma reabsorbs, presumably because fewer neurons are destroyed
than in severe ischemic strokes. Occasionally, early surgical drainage can be
remarkably successful, particularly when the hematoma is in the cerebellum.
Younger, normotensive patients sometimes suffer from spontaneous
intracerebral hematoma from an underlying congenital defect of the blood
vessels. Such abnormalities are commonly arteriovenous malformations (AVMs);
circumscribed areas of dilated and thin-walled vessels which can be demonstrated

angiographically. Patients with AVMs are liable to subsequent rebleeding and
surgical excision is undertaken when possible. Spontaneous intracerebral
hemorrhages (as opposed to traumatic ones) are mainly due to arteriolar
hypertensive disease and more rarely due to coagulation disorders, vascular
malformation within the brain and diet (such as high alcohol consumption,
low blood cholesterol concentration, high blood pressure, etc.). Cortical amyloidal
angiopathy (a consequence of hypertension) is a cause of cortical hemorrhages
especially occurring in elderly people and it is becoming increasingly frequent
as populations become older.
Subarachnoid Hemorrhage (SAH)

Between 5 and 10 percent of strokes are due to subarachnoid hemorrhage
with bleeding into the subarachnoid space, usually arising from a berry aneurysm
situated at or near the circle of Willis. The most common site is in the region
of the anterior communicating artery with posterior and middle cerebral artery
fusions almost as frequent. Congenital factors play some part in the etiology
of berry aneurysms but it is not predominantly a disease of the young, since
hypertension and vascular disease lead to an increase in aneurysm size and
subsequent rupture.
The patient complains of sudden intense headache often associated with
vomiting and neck stiffness. Consciousness may be lost and about 10% will
die in the first hour or two. Of those that remain, 40% will die within the
first 2 weeks and the survivors have a substantially increased risk from rebleeding
for the next six weeks or so. A hemiplegia may be evident at the outset,
if the blood erupts into the deep parts of the brain and other focal neurological
signs may evolve over the first two weeks because there is a tendency for
blood vessels, tracking through the bloody subarachnoid space, to go in spasm
leading to secondary ischemic brain damage. Early investigation by angiography,
followed by a competent neurosurgical procedure to clip the aneurysm and
prevent rebleeding offers the best hope for recovery.
LESS FREQUENT CAUSES OF STROKE

Stroke may occasionally occur in the context of a generalized medical disorder
which either affects the arteries or the blood going through them. An arteritis
or inflammation of the arteries may complicate meningitis, particularly
tuberculous and strokes are relatively common in tertiary syphilis. The collagen
vascular diseases, particularly systemic lupus erythematosus (SLE) and
polyarteritis nodosa, may affect medium and small cranial arteries. Temporal
arteritis, an inflammatory condition predominantly affecting the extracranial
and retinal arteries in the elderly, may also give rise to stroke by intracranial
involvement. Bacterial infection of damaged heart valves (bacterial endocarditis)
is sometimes complicated by stroke, either as result of an immune-mediated
arteritis or as a consequence of septic emboli impacting in the cranial arteries.
Emboli may also arise from left atrium in patients with atrial fibrillation,
particularly if there is coincidental mitral stenosis. More recently, an association
between mitral valve prolapse (floppy valve), which is a fairly common
congenital abnormality and ischemic stroke has been demonstrated.
Hematological diseases such as polycythemia rubra vera, thrombocythemia
and sickle cell disease can provoke stasis in the intracranial arteries, thus
leading to ischemic brain damage. Completed stroke, occasionally, complicates
severe migraine if the vessel spasm, which normally produces only temporary
symptoms, is of such intensity and such duration that ischemic damage occurs.
Finally, there is some evidence that women taking the contraceptive pill,
particularly if it has high estrogen content, suffer slightly higher incidence
of stroke than those not on the pill. The absolute risk is small but enhanced
by cigarette smoking.
THE STROKE-PRONE POPULATION

Once a stroke has occurred, neurons are irreparably damaged but there is
a border zone around the infarct where non-functioning neurons may still
be viable if an adequate blood supply can be restored. There is no certain
way of doing this at present and so much attention has concentrated on trying
to define those subjects in the normal population who are at-risk from having
a stroke before they show signs of a compromised cerebral circulation. The
risk factors might then be amenable to treatment in the hope that the stroke
could be prevented from occurring. The most comprehensive epidemiological
study to date has been conducted in Framingham, Massachusetts (Kannel and
Wolf, 1983) and the first point to emerge is that while the chance of having
a stroke increases with age, it should not be considered as a natural concomitant
of increasing age. The most significant risk factor to emerge is hypertension,
either systolic (>160 mmHg) or diastolic (>90 mmHg.) The risk of stroke
increases dramatically with increasing blood pressure and there is good evidence
that prophylactic hypertensive therapy alleviates this susceptibility. Patients
with diabetes are also much more likely to suffer a stroke than subjects with
normal blood glucose. Abnormal blood lipids, smoking and positive family
history are independent risk factors but their effect is relatively minor. The
‘final common pathway’ for all these risk factors is the arterial disease
atherosclerosis, a disease of the larger and medium-sized arteries characterized
by the deposition of cholesterol and other substance in the arterial wall. The
irregular vessel wall provokes clot formation in the lumen of the artery, which
may completely occlude the vessel or may dislodge to form emboli. Hypertension
and other risk factors, therefore, predispose to ischemic strokes, the most usual
cause for intracerebral hematoma is also hypertension and the associated small
vessel disease (lipohyalinosis).
RISK FACTORS FOR

CEREBROVASCULAR DISEASE
Many risk factors for stroke have been described. They may refer to inherent
biological traits such as age and sex, physiological characteristics that predict
future occurrence such as high blood pressure, serum cholesterol, fibrinogen;
behaviors such as smoking, diet, alcohol consumption, physical inactivity; social
characteristics such as education, social class and ethnicity; and environmental
factors that may be physical (temperature, altitude), geographical, or
psychosocial. In addition, medical factors including previous TIA or stroke,
ischemic heart disease, atrial fibrillation and glucose intolerance, all increase
the risk of stroke.
At a population level, blood pressure and tobacco use are the two most
important modifiable risk factors for stroke due to their strong associations,
high prevalence and the possibility for intervention. Epidemiological research
has shown that raised blood pressure is the single most important risk factor
for ischemic stroke with a population attributable risk of 50%. The risk of
stroke rises steadily as blood pressure level rises and doubles for every 7.5
mmHg increment in diastolic blood pressure, with no lower threshold. Treatment
with antihypertensive treatment has been shown to reduce stroke risk by about
38%.
Tobacco use increases the risk of ischemic stroke by about two-fold and
is furthermore also associated with a higher risk of hemorrhagic stroke. There
is a dose-response relationship so that heavy smokers are at a higher risk
of stroke than light smokers. Until recently, studies of tobacco use and stroke
focused on smoker’s risk, however, exposure to environmental tobacco smoking
is also an independent risk factor for stroke. This study suggested that previous
analyses based on reference groups without differentiating exposure between
non-smokers might have led to a general underestimation of the risk of stroke
in smokers. While most studies of risk factors for ischemic stroke are based
on data from populations in developed countries, there is some evidence from
developing countries that many of the risk factors are similar including blood
pressure, tobacco use, and obesity. There are estimated 1.2 billion smokers
worldwide. In China alone, there are 300 million smokers. A review on obesity
from Latin-American countries showed that the prevalence of over-weight people,
especially in urban areas, may be as high as the prevalence reported in developed
nations. The present knowledge on the prevalence of major risk factors in
developing countries is, however, very limited.
Risk factors for stroke:
 Hypertension
 Heredity
 Diabetes mellitus
 Transient ischemic attacks (TIA)
 Cardiac abnormalities
 Carotid bruit
 Hyperlipidemia
 Estrogen contraceptive pill
 Cigarette smoking
 Elevated hematocrit.
CAUSES OF ISCHEMIC STROKE

Thrombosis:
 Atherosclerosis
 Arteritis:
– Temporal arteritis
– Granulomatous arteritis
– Polyarteritis
– Wegener’s granulomatosis
– Granulomatous arteritis of great vessels (Takayasu’s arteritis, syphilis)
 Dissections:
– Carotid
– Vertebral
– Intracranial arteries at the base of the brain (spontaneous or traumatic)
 Hematological disorders:
– Polycythemia 1° or 2°
– Sickle cell disease
– Thrombotic thrombocytopenic purpura, etc.
 Cerebral mass effect compressing intracranial arteries:
– Tentorial herniations—post cerebral artery
– Giant aneurysm—middle cerebral artery
 Miscellaneous:
– Moyamoya disease
– Fibromuscular dysplasia
– Binswanger’s disease
Vasoconstriction:
 Cerebral vasospasm following SAH
 Reversible cerebral vasoconstriction:
– Etiology unknown, following migraine, trauma, eclampsia of pregnancy.
Embolism:
 Atherothrombotic arterial source:
– Bifurcation common carotid artery
– Carotid siphon
– Distal vertebral artery
– Aortic arch
 Cardiac source:
– Structural heart diseases
 Congenital: Mitral valve prolapse, patent foramen ovale, etc.
 Acquired: Following MI, marantic vegetation, etc.
– Dysrhythmia, atrial fibrillation, sick sinus syndrome, etc.
– Infection, acute bacterial endocarditis
 Unknown source:
– Healthy child or adult
– Associations
 Hypercoagulable state secondary to systemic disease
 Carcinoma, particularly pancreatic
 Eclampsia of pregnancy
 Oral contraceptive pills
 Lupus
 Anticoagulants
 Factor C deficiency
 Factor S deficiency, etc.
THREATENED STROKE
Transient ischemic attacks (TIAs)

A transient ischemic attack refers to a stroke-like syndrome in which recovery
is complete within 24 hours. They are important to recognize because some
patients (about 10% per year) will go not to have a complete stroke. The symptoms
depend on which part of the brain has been temporarily deprived of blood.
The symptoms evolve rapidly and resolve more gradually, but it is unusual
for the whole episode to last more than an hour and there are no permanent
neurological deficits. Sometimes the retinal artery is involved, and here; the
patient complains of a unilateral visual field disturbance, or blindness, often
descending like a curtain across the vision. Within half-an-hour or so (often
much more rapidly), the veil lifts vision is restored. This syndrome is known
as amaurosis fugax and it is particularly important because observations have
been made on patients during the attacks which have thrown light on the
mechanism of TIA in general.
By the use of ophthalmoscope, the observer can see the retinal vessel and
several authors have reported small platelet and cholesterol plugs, blocking
the retinal arteries during an attack of amaurosis fugax (Fisher, 1959). These
plugs subsequently disperse, blood flow is re-established and vision recovers.
The emboli may come from atherosclerotic plaques in the internal carotid
artery, sometimes the heart acts as the source, and it is argued that TIAs
characterized by hemispheric disturbances are due to the same process, with
emboli ascending to the cerebral rather than the ophthalmic and retinal vessels.
Brainstem TIA also occurs with symptoms ranging from transient vertigo to
sudden loss of consciousness, and here emboli is thought to arise from the
vertebral arteries, aorta and heart. The importance of TIA is that if source
of emboli can be defined, then it is sometimes amenable to surgery. For example,
carotid endarterectomy or medical treatment with antiplatelet drugs such as
aspirin can be useful.
Leaking Aneurysm
About 40% of patients who develop a subarachnoid hemorrhage due to rupture
of an aneurysm have preceding symptoms which suggest minor leaks. These
usually occur within a month of the major bleed and often go unrecognized
by the patient and doctor alike. Symptoms which suggest a minor subarachnoid
bleed are sudden headache accompanied by nausea, photophobia and sometimes
neck stiffness. The symptoms can resolve rapidly and may be incorrectly
attributed to migraine. If a bleed is suspected then it should be confirmed
by CT scan and/or lumbar puncture because most of these patients will go
on a major bleed with devastating consequences. The operative risk in a healthy
subject who has a minor bleed is much less than in the patient who has suffered
a major subarachnoid hemorrhage.
Asymptomatic Carotid Bruit

A noise (or bruit) is sometimes heard over the carotid artery during the routine
medical examination. The bruit suggests turbulent blood flow due to underlying
atherosclerosis and it is referred to as asymptomatic carotid bruit if present
in an otherwise healthy individual. Some 5% patients per year who have a
bruit will not have a stroke, though not always in the distribution artery.
STROKE MIMICS
Following an ischemic stroke, interventions to bring about reperfusion must
be implemented within the recognized timeframe; this means that timely clinical
recognition of this condition is vital. The process of diagnosis begins with
the initial bedside assessment of the patient to be followed by appropriate
imaging studies. However, because reperfusion therapy may be attended by
significant adverse consequences and since imaging may be negative for many
hours after stroke onset, the clinician must be aware of conditions that mimic
cerebral ischemia.
STROKE IN THE YOUNG INDIAN POPULATION

Most of the studies carried out in India have shown that about 10–15% of
strokes occur in those below 40 years of age, which is high compared to
other countries. This could be due to many local etiological factors. Previously,
causes contributing to stroke in the young were reported as meningovascular
syphilis in men, puerperal cerebral venous thrombosis in women and rheumatic
heart disease in both sexes. A disturbance in the balance of coagulation and
fibrinolysis has been suggested in the etiopathology of non-embolic cerebral
infarction in the young. Other studies have incriminated subacute tubercular
meningitis, leading to arteritis or autoimmune angiitis, as an important risk
factor in India. More recently reported risk factors among the young include
viper envenomation, elevated lipoprotein (a) and elevated anticardiolipin
antibodies. A recent Indian study suggests that the squatting posture adopted
in the toilet could be an important triggering factor for stroke in Indians,
by the mechanism of raising the blood pressure.
OTHER UNUSUAL CAUSES OF

STROKE IN CHILDREN
Stroke is always a consideration when a previously healthy child or infant
suddenly develops focal neurological disturbance. Half of these cases are of
ischemic etiology and half are non-traumatic intracerebral and subarachnoid

hemorrhages arising from vascular malformation. In children, ischemic stroke
may be precipitated by a hemoglobinopathy (e.g. sickle cell anemia),
hypercoagulable state, congenital and rheumatic heart disease, trauma, vasculitis,
and vasculopathies such as MELAS (mitochondrial myopathy, encephalopathy,
lactic acidosis, and stroke-like episodes). Nonvascular causes of focal
neurological disturbances include alternating hemiplegia, migraine, seizures,
Kawasaki disease, trauma and space occupying lesions.
STROKE WITH ATYPICAL PRESENTATION

Strokes with atypical presentations that take on the appearance of other disease
process may change and evolve with time. The clinician is left with the daunting
problem of discovering the unusual manifestation of an uncommon clinical
process. A seemingly infinite number of unusual clinical syndromes have been
attributed to ischemic stroke after thorough investigation. The presence of
historical risk factors for cerebrovascular disease and the abrupt onset of
symptoms may be the best clues available to the emergency physician to detect
these unusual stroke syndromes. A few that are of clinical importance are
briefly summarized:
 Most strokes present as a deficit or loss of function. Uncommonly, movement
disorders will present due to a focal lesion such as an ischemic stroke
or hemorrhage. Acute hemiballismus or unilateral dyskinesias often result
from acute vascular lesions in the subthalamic nucleus or connections. The
movements may vary from wild flinging movements to mild uncontrollable
unilateral movements. The key to diagnosis is the abrupt onset of symptoms
and the presence of risk factors for cerebrovascular disease. A review note
that any kind of dyskinesias, hypokinetic as well as hyperkinetic, may be
found from lesions at many different levels in the frontal motor cortical
and subcortical regions.
 Confusional states, agitation, and delirium have all been reported as a
consequence of focal neurologic injury; structures involving the limbic
cortex of the temporal lobes and the orbitofrontal regions are commonly
involved. These states must be distinguished from the neglect syndromes
and fluent aphasias in which patients are often reported as confused but
careful examination demonstrates a clear focal deficit. In syndromes of
visual neglect especially, testing for visual fields will reveal a dramatic
field cut that the patient cannot report since he or she is unaware of
the deficit.
 Sensory complaints of either unusual sensations or loss of sensation are

common in parietal and thalamic strokes. At times, the sensory manifestation
of a stroke may take on the characteristics of another clinical condition.
Chest pain and limb pain that mimicked that of myocardial infarction were
reported in a small series of patients; most had thalamic strokes but one
had a lateral medullary infarct. Sensory symptoms may occur with lesions
in many places in the central nervous system. Cortical involvement is usually
accompanied by other neurologic deficits such as hemiparesis, aphasia,
hemineglect, or visual field abnormalities.
 Cortical blindness is unusual but may occur; it can be distinguished from
bilateral ocular disease by the normal pupillary light responses and normal
optic disks. As many as 10% of patients with cortical blindness deny visual
symptoms (Anton’s syndrome); at times, there is an element of ‘blind sight,’
with patients retaining some residual visual ability in their blind areas.
For example, patients with blind sight may make correct ‘guesses’ about
movements or colors of objects in the visually deficient areas, demonstrating
some remnant perception of which they are not consciously aware.
Clinical Diagnosis of Neurological Condition 41
C H A P T E R
4
Clinical Diagnosis of
Neurological Condition
INTRODUCTION
As in other branches of medicine, the art of the neurologist consists of making
a diagnosis from the patient’s own account of his illness and from a physical
examination aided by appropriate radiographic or laboratory tests. Once the
diagnosis has been reached, suitable treatment can be given and the outlook
predicted. What distinguishes neurology from its sister specialties, is the degree
of attention to detail in taking the medical history and in examining the patient.
This quest detail, so mysterious to the non-neurologist, is linked to a wealth
of knowledge of nervous anatomy, physiology and pathology, accumulated
over more than a century, the application of which at the bedside often enables
a precise diagnosis to be made. Now that computerized tomography (CT-
scanning) and magnetic resonance imaging (MRI) have become generally
available, the brain can be X-rayed as readily as the chest, resulting in a
trend toward simpler clinical neurological assessment.
BEDSIDE ASSESSMENT OF STROKE

Simultaneous to the process of confirming the diagnosis of stroke, there needs
to be an ongoing assessment at the bedside. The initial evaluation of a potential
stroke patient is similar to that of other critically ill patients: Stabilization
of airway, breathing and circulation (ABC). This is quickly followed by a
secondary assessment of the neurological deficits and possible comorbidities.
The overall goal is not only to identify patients with possible stroke but also
to exclude stroke mimics, identify other conditions requiring immediate
intervention and determine potential causes of the stroke for early secondary
prevention. A good history and a thorough physical examination to elicit the

associated signs may help in differentiating stroke from the common mimics.
NEUROLOGICAL CASE HISTORY

For the neurologist, a complete and accurate history is essential. Very often
a precise diagnosis can be made from the history, and examination is simply
confirmatory; the converse, a physical examination which provides signs not
predicable from the history, tends to come as a surprise. Although it may
not be absolutely accurate, some early historical data and clinical findings
may direct the physician toward a diagnosis of another cause for the patient’s
symptoms. Alteration of mental status or loss of consciousness, in the absence
of lateralizing symptoms or signs, points towards metabolic or other causes
of encephalopathy. March of symptoms or positive symptoms is indicative
of increased brain activity as seen in seizures. Headache, as the presenting
symptom in the appropriate (young) age-group, is more likely to represent,
migraine, though, it is also a feature seen commonly in stroke.
In addition to the historical aspects of the symptoms, it is important to
ask about risk factors for atherosclerosis and cardiac disease in all patients,
as well as any history of cigarette smoking, migraine, seizure, infection, trauma,
or pregnancy. Historical data necessary for deciding the eligibility of the patient
for therapeutic interventions in acute ischemic stroke are equally important.
Bystanders or family witnesses should be asked for information about onset
time and historical issues, especially when patients are unable to speak or
provide history. A list of the patient’s medications, or the medication containers
themselves, should be sought, with particular attention paid to identifying any
anticoagulant (both oral and injectable), anti-platelet and antihypertensive drug
use.
The description of the tempo of the illness—acute or chronic, coming on
slowly or abruptly, steadily progressive or remitting, often suggests the type
of pathological process. Vascular problems are usually of acute onset, tumor
symptoms and tend steadily to progress, demyelinating disease may remit.
The characterization of symptoms is then attempted, the neurologist assisting
the patient with suitable questions. ‘Headaches’, ‘dizziness’ and ‘fainting’ are
three of the most frequent problems dealt with in neurological clinics. It is
the task of the neurologist to decide if the patient’s headaches are from a
brain tumor or simply from muscular tension or from migraine. Dizziness
may signify disease of the balance mechanisms in the ear and brainstem. Faints
may or may not mean neurological disease: Epilepsy may resemble fainting
attacks and careful enquiry with specific questions is often needed to obtain
a clear picture of such episodes. Other symptoms of special significance to

the neurologist include disturbances of memory or concentration; loss of vision;
double vision; facial pain or weakness; difficulty with speech or swallowing;
weakness, wasting, pain or numbness in a limb; abnormal movements; trouble
with walking; and disturbance of bladder control. Each of these symptoms,
described by the patient, has a range of possible cause which needs to be
considered, thus, it will set in train a particular process of enquiry as the
neurologist attempts on the basis of the information given by the patient —
to form a clear image of the nature and localization of the underlying neurological
disorder.
THE NEUROLOGICAL EXAMINATION

To a certain extent, neurological examination begins from the moment the
patient enters the consulting room. Gait, mental attitude, alertness and speech
may all give important diagnostic clues. However, the formal examination
of the nervous system follows completion of history-taking.
 Testing of the head, trunk and limbs for motor and sensory function is
preceded by an evaluation of mental state and intellectual level.
 The patient’s overall appearance and behavior, mood, orientation, thought
processes memory and intelligence may be affected in many brain diseases
and need to be assessed.
 A disturbance of speech may point to a disorder of the dominant cerebral
hemisphere or of motor control.
 The carotid arteries are felt and listened to in the neck to check on arterial
blood flow to the brain, neck movement is tested and the skull is felt
and listened to for abnormal sounds.
 Functions of the cranial nerves are then examined in turn. Sense of
smell (olfactory nerves); visual fields, visual activity, optic fundi—using
the ophthalmoscope (optic nerves); examination of the pupils (oculomotor
nerves) and of eye movement (oculomotor, trochlear and abducent nerves);
facial sensation, corneal sensation and reflexes, jaw movement (trigeminal
nerves); facial movement (facial nerves); hearing (auditory nerves); palatal
sensation and movement (glossopharyngeal and vagus nerves); movement
of sternomastoid and trapezius muscles (spinal accessory nerves); and
tongue movement (hypoglossal nerves) are the major cranial nerve
functions assessed in a full neurological examination. Abnormalities
observed in any of these will suggest the anatomical basis of the patient’s
complaint.
 The systematic examination of the trunk and limbs includes both motor
and sensory testing; the patient’s symptoms should suggest which of these
is carried out first, since either can be tiring. In order to decide if muscle
function is normal or abnormal, the doctor must first carefully look at the
limbs for signs of muscle wasting, abnormality of posture (suggesting muscular
imbalance), involuntary movement (which may be a sign of extrapyramidal
disease) and fasciculation (often a sign of damage to motor nerve cells).
The neurologist then evaluates the tone of the limb musculature (the state
of tension in the muscles, which may be increased or decreased under abnormal
conditions), assesses power systematically, muscle group by muscle group,
looks for signs of incoordination of movement and tests the tendon reflexes
(which can reveal derangement of function at or above or below the spinal
segments each represents).
 Sensation from different zones of skin is conveyed to the nervous system
via different spinal nerves and spinal cord segments, while distinct forms
of skin sensation (e.g. pain and touch) have separate pathways in the nervous
system. Clearly, careful sensory testing can also be of great localizing value.
In practice, the neurologist will often test pain sensation with a pin, touch
with a piece of cotton wool and joint position sense by carefully moving
a finger or toe. He makes much use of the vibration of a tuning fork as
an overall test of sensory function.
PHYSICAL EXAMINATION
 The general physical examination continues from the original assessment
of the airway, breathing and circulation (ABC) and should include pulse
oximetry and body temperature.
 Examination of the head and neck may reveal signs of trauma or seizure
activity (e.g. contusions or tongue biting), carotid disease (bruits), or
congestive heart failure (jugular venous distension).
 The cardiac examination focuses on identifying concurrent myocardial
ischemia, valvular conditions and irregular rhythm and, in rare cases, aortic
dissection, which could precipitate a cardioembolic event.
 The respiratory and abdominal examinations seek to identify other co-
morbidities.
 Examination of the skin and extremities may also provide insight into
important systemic conditions such as hepatic dysfunction, coagulopathies,
or platelet disorders (e.g. jaundice, purpura, or petechia).
NEUROLOGICAL EXAMINATION AND STROKE

SCALE SCORES
The emergency physician’s neurological examination should be brief but
thorough. It is enhanced by use of a formal stroke score or scale, such as
the NIH Stroke Scale (NIHSS). It enables examiners to rapidly detect focal
neurological deficits. In addition, it may help quantify the neurological deficit
resulting from a stroke and is useful in monitoring progress with stroke treatment
such as thrombolysis. The scale can be used by a broad spectrum of non-
neurological healthcare providers. Use of a standardized examination helps
to ensure that the major components of a neurological examination are performed
in a timely fashion. These scores not only help to quantify the degree of
neurological deficit but also facilitate communication between healthcare
professionals, identify the possible location of vessel occlusion, provide early
prognosis and help to identify patient eligibility for various interventions and
the potential for complications. It may also have some predictive value in
detecting stroke mimics. Several studies have demonstrated that emergency
physicians committed to stroke care may correctly identify and safely treat
stroke patients, especially with the use of such standardized scales. Access
to neurological expertize when required may benefit care of the stroke patient.
DIAGNOSTIC TESTS
Diagnostic tests should be performed routinely in patients with suspected
ischemic stroke to identify systemic conditions that may mimic or cause stroke
or that may influence therapeutic options. Neuroimaging in the form of CT
and MRI are critically important. While non-contrast CT scan is useful in
distinguishing hemorrhagic from ischemic stroke, it is of limited diagnostic
value in differentiating stroke from stroke mimics. It may remain normal up
to 24 hours from symptoms onset in ischemic stroke patients. Contrast CT,
including CT perfusion (CTP) and CT angiogram (CTA), can contribute
significantly to this differentiation. An abnormal CTP or CTA will not only
aid in confirming the diagnosis of ischemic stroke, but also enable detection
of contrast-enhancing lesions such as tumor and abscess. MR diffusion-weighted
imaging has been found to have a high sensitivity and specificity in the early
diagnosis of ischemic stroke. Perfusion-weighted imaging, which requires MR
imaging with contrast, may be a useful adjunct to non-contrast DWI in confirming
the diagnosis of ischemic stroke.
In addition to the neuroimaging modalities, blood tests are useful in the
diagnosis of the stroke mimics. These tests include blood glucose measurement,
complete blood count with platelet count, prothrombin time, activated partial
thromboplastin time, international normalized ratio and renal function studies.
Hypoglycemia may cause focal symptoms and signs that mimic stroke and
hyperglycemia is associated with unfavorable outcomes. Determination of the
platelet count and, in patients taking warfarin or with liver dysfunction, the
prothrombin time/international normalized ratio is important. Because time
is critical, it is advocated that thrombolytic therapy should be started for stroke
patients while awaiting the results of the prothrombin time, activated partial
thromboplastin time, or platelet count; therapy with thrombolytic drugs is
withheld in absence of these test results, if a bleeding abnormality or
thrombocytopenia is suspected, if the patient has been taking warfarin and
heparin, or if there is any uncertainty regarding anticoagulation use.
FURTHER TESTS
Radiographs
These are invaluable for disease affecting the bones of the skull and the spine.
However, they cannot show the soft tissue contained inside. For these to be
seen, it is necessary either to inject into the blood vessels of the brain or
cord a substance which is opaque to X-rays (angiography) or to outline the
nervous tissue by defining the fluid spaces within and outside them, using
air or an opaque medium (pneumoencephalography or ventriculography for
the brain; myelography for spinal cord). The selective uptake of radioactive
isotopes by diseased nervous tissue can be used to produce images of the
brain (isotope scans).
The CT scanner, mentioned earlier, gives in many cases a definitive structural
diagnosis. Its principle is the detection of minute changes of tissue density
from point to point inside the head. In this way, radiography of the brain
itself, and not just the skull, can be assembled.
Electrodiagnostic Tests
 These involve the amplification and recording of the electrical activity of
nervous tissue and have certain diagnostic applications. Electro-
encephalography (EEG) is useful in the investigation of some epileptic
patients, in some cases of coma and in certain forms of encephalitis.
 Electromyography is an essential part of the evaluation of patients with
neuromuscular disease. Measurement of sensory and motor nerve conduction
is equally essential in the study of lesions of the peripheral nervous system.
Cerebrospinal Fluid Tests

These are important in neurological diagnosis. Lumbar puncture is the usual
technique for obtaining a sample. It is a necessary procedure where meningitis
or subarachnoid hemorrhage is suspected and it may give useful information
in certain inflammatory diseases of brain tissue. Examination of the cerebrospinal
fluid is indicated if the patient has symptoms suggestive of subarachnoid
hemorrhage and a CT scan does not demonstrate blood.
Other Tests
 A clinical cardiovascular examination, measurement of serum levels of cardiac
enzymes, and a 12-lead ECG may be performed in all stroke patients. Cardiac
abnormalities are common among patients with stroke and the patient can
have an acute cardiac condition that mandates urgent treatment. For example,
acute myocardial infarction can lead to stroke and acute stroke can lead
to myocardial ischemia.
 In addition, cardiac arrhythmias can occur among patients with acute
ischemic stroke. Atrial fibrillation, an important potential cause of stroke,
can be detected in the acute setting. Cardiac monitoring should be conducted
routinely after an acute cerebrovascular event to screen for serious cardiac
arrhythmias.
 Although CT scan is more sensitive than MRI in detecting subarachnoid
blood in the acute phase, in the subacute phase, MRI sequences, in particular
gradient-echo T2 images followed by fluid-attenuated inversion recovery
(FLAIR) images, are considered to be the most sensitive. The clinical features
of subarachnoid hemorrhage differ considerably from those of ischemic
stroke. Cerebrospinal fluid analysis may be of additional value when CNS
infection needs to be excluded as the cause for the stroke-like presentation.
 Electroencephalography may be helpful for evaluating patients in whom
seizures are suspected as the cause of the neurological deficits or in whom
seizures could have been a complication of the stroke. Seizure in the absence
of imaging confirmation of acute ischemia is a relative contraindication
for the use of rt-PA in acute ischemic stroke.
 Additional tests may be performed as indicated by the patient’s history,
symptoms, physical findings, or comorbidity. A toxicology screen, blood
alcohol level, arterial blood gas and pregnancy test should be obtained
if the physician is uncertain about the patient’s history or if suggested by
findings on examination.
In summary, bedside assessment is important in distinguishing stroke from
stroke mimics. Blood tests and brain imaging are often useful adjuncts to
bedside assessment. The latter may play critical roles in identification of stroke,
decision to treat and prioritization of tests, in view of the fact that thrombolytic
therapy carries the risk of bleeding and is often limited by a narrow time
window of opportunity. Despite recent advances in stroke therapy, the majority
of stroke patients do not seek immediate medical attention. Even in developed
countries like USA, UK and France, there is a lack of knowledge among
stroke patients about warning symptoms and risk factors. In a multicenter
survey in USA, over one-half of the patients at increased risk for stroke were
unaware of their risk factors. This study reveals the importance of the need
of research in India. Intravenous (IV) recombinant tissue plasminogen activator
(rt-PA) is being used for acute ischemic stroke in India. Knowledge about
stroke warning symptoms and risk factors is essential for the patients to effectively
utilize the thrombolytic therapy for acute stroke. In country like India, studies
regarding stroke patients’ knowledge about warning symptoms and risk factors
should be carefully evaluated for prompt treatment and hence reduction in
overall disability.
Symptoms of Brain Damage 49
C H A P T E R
5
Symptoms of
Brain Damage
CNS DISORDERS AND BRODAL’S PASSAGE

Anatomist Brodal (1973)
A Norwegian anatomist named Brodal, suffered stroke and reports his own
experiences.
The patient had found that destruction of even a minor part of the brain
causes changes in number of functions, which are difficult to study objectively.
They were, however, very obvious to him. They are what one might call
general deficits of the brain.
 Loss of concentration power
 Reduced short-term memory
 Reduced initiative
 Incontinence of movements of emotional expression and other phenomena.
It has also been astonishing to note how long it takes for these symptoms
to improve visibly. Even after ten months, if the patient seems to be as he
was, apart from his slight remaining paresis, he is painfully aware that this
is not so.
CNS Disorders
CNS lesions or stroke produces sudden and devastating trauma to the entire
personality. Main problems arising from the “functional disturbances” are very
complex:
 Somatosensory
 Motor
 Speech and language
 Visuospatial
 Cognitive
 Perceptual
 Behavioral.
These disturbances are frequent causes of disability ranging from moderate-
to-severe depending upon the side, site and area of lesion. The stroke divides
the body into two separate halves, distorting the body symmetry and image
and causing alien arm syndrome in left hemiplegics. The cortex is subject
to faulty sensory input misinformation resulting in derangement of entire normal
postural reflex mechanism causing:
 Weakness (hemiparesis) or paralysis (hemiplegia) on one side of the body
that may affect the whole side or just the arm or leg; the weakness or
paralysis is on the side of the body opposite the side of the brain affected
by the stroke
 Spasticity, stiffness in muscles and painful muscle spasms
 Problems with balance and/or coordination
 Problems using language, including having difficulty understanding speech
or writing (aphasia); and knowing the right words but having trouble saying
them clearly (dysarthria)
 Being unaware of or ignoring sensations on one side of the body (body
neglect or inattention)
 Pain, numbness or odd sensations
 Problems with memory, thinking, attention or learning
 Being unaware of the effects of a stroke
 Trouble in swallowing (dysphagia)
 Problems with bowel or bladder control
 Fatigue
 Difficulty controlling emotions (emotional liability)
 Depression
 Difficulties with daily tasks.
Spasticity
The concepts and origins of spasticity are also changing; it has always
become a controversial subject with the neurophysiologist. Earlier
believed to be due to overactivity of the myotatic stretch reflex of
the muscle spindle and loss of inhibitory cortical control, is today
believed to be due to hyperactivity of long tracts—corticospinal,
vestibular spinal and reticulospinal. This is the outcome of the recent
studies of spindle activity by neuroelectrodes of selected nerve trunks
which did not correlate well with the hyperactive tendon reflex.
Sensations
Impairments result in distorting information from the self and environment
affecting:
 Superficial sensations
 Joint position sense
 Perceptual: This refers to activity occurring in secondary and tertiary sensory
associated areas of the cortex which integrate information such as memory,
context and experience.
Lesions in parietal lobes disturb sensory integration:
 Neglect
 Hemianopia
 Unawareness of the body parts, distorted body image and left-right
disorientation
 Inability to localize body parts
 Alien-arm syndrome
 Bizarre statements regarding body parts and position of their limbs
 Referring to paralyzed limbs with different names
 Inattention and increased fatigue
 Lack of concentration and initiative
 Emotional liability
 Reduced short-term memory
 Speech without context
 Underestimating the gravity of the disability
 Studies of lesions in CNS have shown that:
– Corticospinal and rubrospinal tracts are important for distal muscle control
and function
– Vestibular reticulospinal tracts are more critical for maintenance of posture
and postural adjustments, balance, position of head in space, body righting,
ocular stability and proximal motor control
– Basal ganglia and cerebellum and vestibular system are critical for balance
and postural adjustment and most important for ensuring harmonious,
coordinated and most precise performance of movements.
Successful rehabilitation depends on:
 Amount of damage to the brain
 Skill on the part of the rehabilitation team
 Cooperation of family and friends. Caring family/friends can be one of
the most important factors in rehabilitation
 Timing of rehabilitation—the earlier it begins, the more likely survivors

are to regain lost abilities and skills.
The goal of rehabilitation is to enable an individual who has experienced
a stroke to reach the highest possible level of independence and be as productive
as possible. Because stroke survivors often have complex rehabilitation needs,
progress and recovery are unique for each person. Although a majority of
functional abilities may be restored soon after a stroke, recovery is an ongoing
process.
 Hospital programs: In an acute care facility or a rehabilitation hospital.
 Long-term care facility with therapy and skilled nursing care
 Outpatient programs
 Home-based programs.
Preventing Another Stroke

Stroke
People who have had a stroke are at an increased risk of having another
one, especially during the first year following the original stroke.
The following factors increase the risk of having another stroke if they do
not modify their previous lifestyle:
 High blood pressure (hypertension)
 Cigarette smoking
 Diabetes
 Having had a TIA (transient ischemic attack)
 Heart disease
 Older age
 High cholesterol
 Obesity
 Sedentary lifestyle.
Although some risk factors for stroke cannot be changed (e.g. age), others
such as high blood pressure and smoking can be altered. Patients and families
should seek guidance from their physician about lifestyle changes to help
prevent another stroke.
SITES OF LESION AND CLINICAL MANIFESTATION

(TABLE 5.1)
Hemiplegia that spares cranial musculature may be caused by a lesion in the
lateral column of the spinal cord at cervical level. Usually, the symptoms
TABLE
Sites of lesion and clinical manifestation
5.1
Site of lesion Clinical manifestation
Cerebral cortex, cerebral white Weakness or paralysis of face, arm,
matter, internal capsule and leg in the contralateral side
Cortical or subcortical Convulsive seizures, aphasia, astereo-
gnosis, two point discrimination loss,
anosognosia
Small discrete lesion in posterior Pure motor hemiplegia affecting the
horn of internal capsule, cerebral face, arm and leg
peduncle, or medullary pyramids
Corticospinal, corticobulbar Paralysis of face, arm, and leg in
tracts in upper brainstem contralateral side, cranial nerve deficit
on same side
Brainstem syndrome Paralysis of oculomotor nerve on same
side with contralateral limb paresis
is known as Weber’s syndrome
Low pontine lesions Same sided abducent or facial palsy
combined with contralateral limb
paresis is known as Millard Gubler
syndrome
Medulla Affect the tongue, sometimes pharynx
and larynx on one side and arm and
leg on the other side
Basis pontis Ataxic hemiplegia with or without
dysarthria
are bilateral and hence, result in quadriplegia. Homolateral paralysis, if combined

with a loss of vibratory and position sense on the same side and contralateral
loss of pain and temperature is known as Brown-Séquard Syndrome.
Muscle atrophy of minor degree is often associated with hemiplegia
but never reaches the proportions seen in diseases of the lower motor
neurons. The reason for this is the disuse of the affected part. There
is an important exception in this rule: when the motor cortex and
adjacent parts of the parietal lobe are damaged in infancy or childhood,
the normal development of the muscles and the skeletal system in
the affected limbs is retarded and the palsied limbs and even the
trunk on one side are small. If hemiplegia occurs after reaching the
puberty, the skeletal system and hence, the size of the body parts
are not affected.
SIGNS AND SYMPTOMS AND

STRUCTURES INVOLVED
See Table 5.2.
TABLE Signs and symptoms and the structures involved
5.2
Signs and symptoms Structures involved
Paralysis of the contralateral face, Somatic motor area for face and arm
arm and leg, sensory impairment and the fibers descending from the leg
over the same area area to enter the corona radiata and
corresponding somatic sensory system
Motor aphasia Motor speech area of the dominant
hemisphere
Central aphasia, word deafness, Central, suprasylvian speech area and
anomia, jargon speech, sensory parietooccipital cortex of the
agraphia, acalculia, alexia, finger dominant hemisphere
agnosia, right-left confusion
(Last four- Gerstmann syndrome)
Conduction aphasia Central speech area (parietal
operculum)
Apractognosia of the minor Nondominant parietal lobe, loss of
hemisphere (amorphosynthesis), topographic memory is usually due to
anosognosia, hemiasomatognosia, a nondominant lesion, occasionally
unilateral neglect, agnosia for the to a dominant one
left half of external space, dressing
apraxia, constructional apraxia,
distortions of visual coordinates,
inaccurate localizations in the left
field, impaired ability to judge
distance, upside down reading,
visual illusions
Homonymous hemianopia Optic radiation deep to 2nd temporal
convolution
Paralysis of conjugate gaze to Frontal contraversive field of fibers
opposite side projecting there from
Paralysis of opposite foot and leg Motor leg area
A lesser degree of paresis of Arm area of cortex, or fibers
opposite arm descending to corona radiata there
from
Urinary incontinence Sensory motor area in paracentral
lobule
Cortical sensory loss over toes, Sensory area for foot and leg
foot and leg
Contd...
Contd...

Contralateral grasp reflex, sucking Medial surface of the posterior frontal
reflex, gegenhalten (paratonic lobe, supplemental area
rigidity)
Abulia (akinetic mutism), slowness, Uncertain localization—probably
delay, intermittent interruptions, cingulate gyrus and medial inferior
lack of spontaneity, whispering, portion of frontal, parietal, and
reflex distraction to sight and sound temporal lobes
Impairment of gait and stance Frontal cortex near leg motor area
(gait apraxia)
Dyspraxia of left limbs, tactile Corpus callosum
aphasia in left limbs
Homonymous hemianopia Calcarine cortex or optic radiation
Bilateral homonymous hemianopia, Bilateral occipital lobe with possibly
cortical blindness, awareness or the parietal lobe involvement
denial of blindness, tactile naming,
achromatopsia (color blindness),
failure to see to-and-fro movements,
inability to perceive objects not
centrally located, apraxia of ocular
movements, inability to count or
enumerate objects, tendency to run
into things which the patient sees
and tries to avoid
Verbal dyslexia without agraphia, Dominant calcarine lesion and
color anomia posterior part of corpus callosum
Memory defect Hippocampal lesion bilaterally or on
the dominant side only
Topographic disorientation and Nondominant calcarine and lingual
prosopagnosia gyrus
Simultagnosia, hemivisual neglect Dominant visual cortex, contralateral
hemisphere
Unformed visual hallucinations, Calcarine cortex
peduncular hallucinosis, meta-
morphopsia, teleopsia, illusory
visual spread, irreminiscence,
palinopsia, distortion of outlines,
central photophobia
Contd...
TABLE
Contd...
2
Complex hallucinations Usually nondominant hemisphere
Thalamic syndrome: Sensory loss Posteroventral nucleus of thalamus,
(all modalities), spontaneous pain involvement of the adjacent
and dysesthesias, choreoathetosis, subthalamus body or its afferent
intention tremor, spasms of hand, tracts
mild hemiparesis
Thalamoperforate syndrome: Dentothalamic tract and issuing third
Crossed cerebellar ataxia with nerve
ipsilateral third nerve palsy
(Claude’s syndrome)
Weber’s syndrome Third nerve and central peduncle
Contralateral hemiplegia Cerebral peduncle
Paralysis or paresis of vertical eye Supranuclear fibers to third nerve,
movement, skew deviation, sluggish interstitial nucleus of Cajal, nucleus
papillary responses to light, slight of Darkschewitsch, and posterior
miosis and ptosis, (retraction commissure
nystagmus and tucking of the
eyelids may be present)
Contralateral rhythmic, ataxic action Dentothalamic tract
tremor, rhythmic postural or holding
tremor
Medial medullary syndrome
(occlusion of vertebral artery or
branch of vertebral or lower
basilar artery)
1. On side of lesion: Paralysis with Ipsilateral 12th nerve
atrophy of half the tongue
2. Opposite side of lesion: Paralysis Contralateral pyramidal tract and
of arm and leg sparing face, medial lemniscus
impaired tactile and proprioceptive
sense over half side of the body
Lateral medullary syndrome
(occlusion of any of the five vessels
may be responsible—vertebral,
posterior inferior cerebellar,
superior, middle, or inferior
lateral medullary arteries)
Contd...
Contd...

On the side of lesion:
• Pain, numbness, impaired Descending tract and nucleus fifth
sensation over half the face nerve.
• Ataxia of limbs, falling to side Uncertain.
of lesion
• Nystagmus, diplopia, oscillopsia, Vestibular nucleus.
vertigo, nausea, vomiting
• Horner’s syndrome: miosis, Descending sympathetic tract
ptosis, anhydrosis
• Dysphagia, hoarseness, paralysis Issuing fibers 9th and 10th nerve
of palate, paralysis of vocal cord,
diminished gag reflex
• Loss of taste Nucleus and tractus solitarius
• Numbness of ipsilateral arm, Cuneate and gracile nuclei
trunk or leg
On side opposite to lesion:
Impaired pain and thermal sense Spinothalamic tract
over half the body, sometimes face
Totally unilateral medullary syndrome Combination of medial and lateral
syndromes
Lateral pontomedullary syndrome Combination of lateral medullary and
Occlusion of vertebral artery lateral inferior pontine syndromes
Basilar artery syndrome A combination of various brain stem
syndromes plus those arising in
posterior cerebral artery distribution
Bilateral long tract signs, sensory Bilateral long trace, cerebellar and
and motor, cerebellar and peripheral peripheral cranial nerves
cranial nerve abnormalities
Paralysis or weakness of all Corticobulbar and Corticospinal tracts
extremities, plus all bulbar bilaterally
musculature
Medial superior pontine syndrome
(Paramedian branches of upper
basilar artery)
On side of lesion: Cerebellar ataxia Superior and/or middle cerebellar
peduncle
Contd...
Contd...

Internuclear ophthalmoplegia Medial longitudinal fasciculus
Myoclonic syndrome, palate, Localization uncertain
pharynx, vocal cords, respiratory
apparatus, face, oculomotor
apparatus, etc.
On opposite side lesion: Corticobulbar and Corticospinal tracts
Paralysis of face, arm and leg
Rarely touch, vibration, and Medial lemniscus
position are affected
Lateral superior pontine syndrome
(syndrome of superior cerebellar
artery)
On side of lesion: Ataxia of Middle and superior cerebellar
limbs, and gait, falling to side of peduncles, superior surface of
lesion cerebellum, dentate nucleus
Dizziness, nausea, vomiting, Vestibular nystagmus
horizontal nystagmus
Paresis of conjugate gaze-ipsilateral. Pontine contralateral gaze
Skew deviation Uncertain
Horner’s syndrome Descending sympathetic fibers
On side opposite to lesion: Spinothalamic tract
Impaired pain and thermal
sense on face, limbs and trunk
Impaired touch, vibration and Medial lemniscus (lateral portion)
position sense, more in leg than
arm. There is a tendency to
incongruity of pain and touch
deficits
Medial midpontine syndrome
(Paramedian branch of midbasilar
artery)
On side of lesion: Ataxia of limbs Pontine nuclei
and gait, predominantly in bilateral
involvement.
On side opposite to lesion: Corticobulbar and Corticospinal tract
Paralysis of face, arm, and leg
Contd...
Contd...

Variable impaired touch and Medial lemniscus
proprioception when lesion
extends posteriorly
Lateral midpontine syndrome
(short circumflex artery)
On side of lesion: Ataxia of limbs Middle cerebellar peduncle
Paralysis of muscles of mastication Motor fibers or nucleus of fifth nerve
Impaired sensation over side of face Sensory fibers or nucleus of fifth
nerve
On side opposite to lesion: Spinothalamic tract
sense on limbs and trunk
Medial inferior pontine syndrome
(occlusion of Paramedian branch
of basilar artery).
On side of lesion: Paralysis of “Center” for conjugate lateral gaze
conjugate gaze to side of lesion
(preservation of convergence)
Nystagmus Vestibular nucleus
Ataxia of limbs and gait Middle cerebellar peduncle
Diplopia on lateral gaze Abducent nerve
On opposite side of lesion: Corticobulbar and Corticospinal tract
Paralysis of face, arm and leg in lower parts
Impaired tactile and proprioceptive Medial lemniscus
sense over half of the body
Lateral inferior pontine syndrome
(occlusion of anterior inferior
cerebellar artery)
On side of lesion: Horizontal and Vestibular nerve or nucleus
vertical nystagmus, vertigo, nausea,
vomiting, oscillopsia
Facial paralysis 7th nerve
Paralysis of conjugate gaze to Center for conjugate lateral gaze.
side of lesion
Deafness, tinnitus Auditory nerve or cochlear nucleus.
Ataxia Middle cerebellar peduncle and
cerebellar hemisphere.
Impaired sensation over face. Descending tract and nucleus
5th nerve.
Contd...
Contd...

On side opposite to lesion: Spinothalamic tract.
sensation over half the body
may include face.
SEQUENTIAL STAGES
During the early stages of stroke, flaccidity with no voluntary movements
is common. Usually, this is replaced by the development of spasticity, hyper-
reflexia and mass patterns of movement, termed synergies. These are not selective
motor movements but are abnormal reflex activity patterns. Muscles involved
in synergy patterns are often so strongly linked together that isolated movements
outside the mass synergistic patterns are not possible. As recovery progresses,
spasticity and synergies begin to decline and advanced movement patterns
become possible. Bobath et al. described these recovery patterns comparing
it to the normal development sequences of a normal baby from birth to three
years of age.
General pattern of recovery was described in detail by Twitchell and
Brunnstrom, who elaborated the process in to six stages:
Brunnstrom Classification
 Stage 1: Recovery from hemiplegia occurs in a stereotyped sequence of
events that begins with a period of flaccidity immediately following the
acute episode.
No movement of the limbs can be elicited.
 Stage 2: As recovery begins, the basic limb synergies or some of their
components may appear as associated reactions, or minimal voluntary
movement responses may be present.
Spasticity begins to develop.
 Stage 3: Thereafter, the patient gains voluntary control of the movement
synergies, although full range of all synergy components does not necessarily
develop.
Spasticity has further increased and may become severe.
 Stage 4: Some movement combinations that do not follow the paths of
either synergy are mastered, first with difficulty, then with more ease.
Spasticity begins to decline.
 Stage 5: If progress continues, more difficult movement combinations are

learned as the basic limb synergies lose their dominance over motor acts.
Motor movements begin to develop in a normal activity pattern.
 Stage 6: With the disappearance of spasticity, individual joint movements
become possible and coordination approaches normal. From here on, as
the last recovery step, normal motor function achieved, but this last stage
is not achieved by all, for the recovery process can plateau at any stage.
This is the last recovery stage which may plateau at any stage.
Bobath Classification
Bobath collapsed the sequence into three main recovery stages:
 The initial flaccid stage
 The stage of spasticity
 The stage of relative recovery.
Additional investigators have confirmed this pattern of motor recovery
following stroke. Motor recovery occurs in a relatively predictable pattern.
The recovery stages are viewed as sequential, although variability in the clinical
picture at each stage is possible. Not all patients recover fully. Patients may
plateau at any stage, depending upon the severity of their involvement and
their capacity for adaptation. Finally, recovery rates differ among patients.
Also, the recovery of lower limbs is more spontaneous whereas the upper
limb functions and fine motor functions are difficult to achieve for the patient
as well as the treating physiotherapist. Importance of the trunk in influencing
the recovery was ably worked upon by Kabat, B Bobath and Patricia Davies.
Presently, the basis of neurorehabilitation lies in early activation of the stabilizers
of the trunk, to minimize the synergistic patterns and to develop and aid in
near normal selective motor activity. Development of various associated problems
and complications delay or modify the amount and quality of the recovery
as well as patient’s personality is a major factor in determining the overall
recovery.
ALTERATIONS IN TONE OF THE MUSCLES

Recognition of the tonal changes is of vital importance in management of
the patient with stroke. The clinical therapist should understand the difference
between the changes in the tone and synergistic patterns and they should
know the relationship between the two. Flaccidity is usually present immediately
after the stroke and is generally short-lived, lasting hours, days, weeks. Spasticity
emerges in about 90 percent of cases and tends to occur in predictable muscle
groups, commonly the antigravity muscles. The effects of spasticity include

restricted movements and posturing of the limbs.
 In the upper extremity, spasticity is frequently strong in:
Scapular retractors; shoulder adductors, depressors and internal rotators;
elbow flexors and forearm pronators; and wrist and finger flexors.
 In the lower extremity, spasticity is often found in:
Pelvic retractors; hip adductors and internal rotators; hip and knee extensors;
plantar flexors and supinators; and toe flexors.
 Automatic postural tone: The automatic adjustment of muscle tension that
occurs normally in preparation for and during a movement or task may
also be impaired.
Thus, patients with stroke may lack the ability to stabilize proximal joints
and trunk appropriately, with resulting mal-alignment of body segments and
in longstanding cases, fixed musculoskeletal impairments. The loss of automatic
postural adjustment will require the patient to give constant conscious effort
for the maintenance of the posture and hence, would produce large energy
expenditure. Fear of falling off to the ground from sitting and standing position
is common. Few patients are fearful of turning in the bed too. This fear of
falling will increase the protective tone in all the muscles of the body but
the muscles in which the tone is already high due to lesion, will become
more spastic and hence, will further more be difficult for the patient to adjust
and align different body segments to each other.
Effort, stress, fears, emotional state, consciousness of the people watching,
newer places and pain increases tone.
LOSS OF SELECTIVE MOVEMENT

The degree and quality of voluntary control is recorded carefully. Although
many patients with hemiplegia appear able to move all parts of their bodies,
they may be unable to move one part in isolation without other muscles acting
simultaneously, in a stereotyped mass pattern of movement. These synergies
are stereotyped because the muscles that participate in the patterned motion
and the strength of their responses are the same for every effort, regardless
of demand. This primitive pattern response is a voluntary act, initiate when
the patient wishes to perform a task (Perry, 1969). For example, he may be
able to grip only while the elbow flexes and the shoulder adducts, or stand
up with the hip and knee extended and the foot planter flexed. Similarly,
dorsiflexion of the foot may only be possible when the hip and knee are
flexed.
The therapist must remember that not only are the arm and leg affected
but the whole side, and therefore, the trunk will be similarly affected. Movement
does not become effective unless and until the undesired components of
movement is these reflex patterns can be inhibited, at the same time, the
desired components are excited (Kottke, 1980).
SYNERGY PATTERNS
Synergy patterns of the extremities are stereotyped, primitive movement patterns
associated with the presence of spasticity. They may be elicited either reflexly,
as associated reactions, or as voluntary movement patterns. There are two
basic synergies of each extremity: a flexion synergy and an extension synergy
including the Latissimus dorsi, Teres major, Serratus anterior, Finger extensors
and Ankle evertors.
These muscles, therefore, are generally difficult to rehabilitate and represent
important functional limitations for many patients in their activities and in
gait. Loss of isolated movement patterns also has important functional
implications. Usually, upper limbs have dominant flexor synergy, while, lower
limbs will have predominantly extensor synergy. It seems that the nature has
taken care with the development of synergies in a sense that extensor synergy
helps the knee joint to remain in extension and thus, is available for weight
bearing in standing. This may be a very gross activity but nonetheless, in
absence of therapy, the patient can at least stand. In few patients with gross
arthritis in knee joint or in patients with flexor spasms in lower limbs, maintaining
knee extension during getting up from sitting and in standing and walking
is extremely difficult, resulting in delayed rehabilitation. Thus, we can thank
nature in a way that gross walking can be achieved post hemiplegia even
in absence of proper therapy.
REFLEXES
Reflexes are altered and vary according to the stage of recovery. Initially,
stroke results in hypotonia and areflexia. During the middle stages of recovery
when spasticity and synergies are strong, hyperreflexia emerges. Stretch reflexes
become hyperactive and patients typically demonstrate clonus and the clasp-
knife reflex. Cutaneous reflexes (positive Babinski) may be present. Primitive
or tonic reflex patterns may appear in a readily identifiable form. Some of
the clinically important reflexes are documented below.
Tonic Neck Reflexes

Movement of the head elicits an obligatory change in resting tone or movement
of the extremities. Flexion of the neck results in flexion of the arms and
extension of the legs; extension of the neck produces the opposite responses
(symmetric tonic neck reflex-STNR). Head rotation to the left cause extension
of the right arm and leg (jaw limbs) with flexion of the right arm and leg
(skull limbs); head rotation to the right causes the reverse pattern (asymmetric
tonic neck reflex-ATNR).
Tonic Labyrinthine Reflexes

Supine positioning produces an increase in extensor tone, while prone positioning
increases flexor tone (symmetric tonic labyrinthine reflex-STLR).
Tonic Lumbar Reflexes

Rotation of the upper trunk, with respect to the pelvis, influences movement
of the extremities. Rotation towards the hemiplegic side results in flexion
of the hemiplegic upper extremity and extension of hemiplegic lower extremity.
Rotation toward the uninvolved side produces the opposite responses (tonic
lumbar reflex-TLR).
Positive Supportive Reactions

Pressure on the bottom of the hemiplegic foot may produce a strong co-
contraction response of lower extremity extensors and flexors, resulting in
a rigidly extended and fixed limb (positive supporting reaction).
Associated Reactions
Associated reactions are also commonly present. These consist of abnormal,
automatic responses of the involved limb resulting from action occurring in
some other part of the body, either by voluntary or reflex stimulation (e.g.,
yawning, sneezing, coughing, stretching). They are easier to elicit in the presence
of spasticity and frequently interact with tonic reflexes. Generally, although
this is not true in every case, associated reactions elicit the same direction
of movement in the contralateral upper extremity (i.e., flexion evokes flexion),
while in the lower extremity opposite movements are elicited (i.e., flexion
of one lower extremity evokes extension of the other). Newer studies have
proven that this fact is clinically feasible. Therapy for hand and scapular
functions, in which bilateral movement patterns are used, is gaining fast

popularity with good results. Specific associated reactions have also been
identified. Elevation of the hemiplegic arm above the horizontal may elicit
an extension and abduction response of the fingers (Souques’ phenomenon).
Resistance to abduction or adduction produces a similar response in the opposite
limb (adduction elicits adduction) in both the upper and lower extremities
(Ramiste’s phenomenon). Homolateral limb synkinesis is the term used to describe
the mutual dependency that exists between hemiplegic limbs (flexion of the
arm elicits flexion of the leg on the hemiplegic side).
Higher level balance reactions like righting, equilibrium and protective
extension reactions are frequently impaired or absent. Patients may be unable
to maintain their head in its normal upright alignment: face vertical with the
mouth in a horizontal position in response to a change in body position or
movement. Impaired righting reactions are also evident when rotation of either
the head or trunk within the body axis fails to produce a log rolling: trunk
moving as one unit; or segmental rolling: head, upper trunk and then lower
trunk pattern. Lack of equilibrium reactions may cause the patient to lose
balance and fall in response to a change of the center of the mass over the
base of support. Protective extension of either hemiplegic limb, in response
to falling, is also commonly impaired or absent.
Majority of the associated reactions are treated with strong stimulation and
active fixation of the body parts by the patients themselves. Strong stimulation
includes tactile, verbal and visual biofeedback.
Associated movement occurs in the normal person during strenuous activity,
but with hyper-tonicity, they appear as associated reactions in abnormal
stereotyped patterns which inhibit functions. Example of associated movement
in normal subject is the movement of left hand in a painter who is painting
with his right hand. Many such examples can be sited for the associated
movements.
WEAKNESS
Paresis or weakness is a common finding. Patients with spastic hemiparesis
are unable to generate normal levels of force necessary for initiating and
controlling movement or for maintaining posture. Specific changes occur in
both the motor neuron and muscle. The number of functioning agonist motor
units is decreased, by as much as 50 percent at 6 months in some patients
with stroke. The recruitment order of motor units may be altered and firing
rates decreased. Thus, patients have increased difficulties trying to maintain
a constant level of force production. Denervation potentials are common, as
a result of denervation changes in the corticospinal tracts. Changes in muscle

include atrophy of muscle fibers with a greater loss of fast-twitch fibers.
Contraction time is increased with increased fatigability noted in paretic muscle.
Patients consistently report that increased effort produces less than maximum
muscular force.
Active restraint arising from antagonist muscles can influence agonist strength.
Bobath has suggested that spasticity of antagonist muscles is a major factor
in the agonist weakness. Some investigators demonstrated a correlation between
paresis and spasticity in agonist muscles but not with antagonist spasticity.
Inappropriate co-activation of agonist-antagonist muscles is another form of
active restraint and may be more of a factor than spasticity, especially in
rapid and reciprocal contractions. Passive restraint secondary to abnormal
mechanical changes in the soft tissues can also affect agonist strength. Loss
of strength in either of the fast and slow twitch fibers can produce either
loss of optimum force production or loss of optimum sustainability of contraction.
Not all muscle groups are affected equally. The amount of paresis experienced
by the patient may also vary according to specific situational contexts. Thus,
a patient may appear stronger in some functional tasks than in others. Paresis
on the “supposedly normal” unaffected side has also been reported. As a matter
of fact, body segments of each right and left half has influence on each other
via crossing tracts and they work in unison, especially in stabilizing functions.
This rhythm is lost and hence, even the strength of the uninvolved side seems
to be decreased due to the lack of the force couple and lack of stabilization.
INCOORDINATION
Incoordination can result from cerebellar or basal ganglia involvement, from
proprioceptive losses, or from motor weakness. Ataxia of the extremities or
trunk is common in patients with cerebellar lesions. Reciprocal interaction
with graded control of agonist-antagonists muscle pairs and synergistic activation
may be impaired. The stretch reflex responses that allow automatic adaptation
of muscles to changes to posture and movement, are commonly abnormal.
DYSTONIA
Dystonia is a variant of hypertonicity in which there is an increased tone
in a group of muscles, especially during activity. The antagonist muscle group
also contracts during the activity of the agonist group instead of relaxing
and hence, wrying movement occurs. The limbs move as if tied up tightly.
Even with patients having sufficient motor activity, the limbs would not become
functional as the patients have tremendous difficulty in carrying out smooth

and coordinated movements.
MOTOR PROGRAMMING DEFICITS

Hemispheric differences have been reported in the area of movement
control.
 The left hemisphere has a primary role in the sequencing of movements.
Thus, patients with left CVA (right hemiplegia) have increased difficulty
initiating and performing sequences of movements, and may take longer
time to learn a task. They also demonstrate slower movements overall,
with more positioning errors.
 The right hemisphere, on the other hand, may have an increased role in
sustaining a movement or posture. Thus patients with right CVA (left
hemiplegia) characteristically demonstrate motor impersistence (inability to
sustain a movement or posture).
 Patients with left hemisphere lesions are also more likely to present with
apraxia. Apraxia is defined as an inability to perform purposive movements
although, there is no sensory or motor impairment. Problems exist in
performing previously learned movements, gestures, and sequences of
movements. Two categories of apraxia are:
– Ideomotor, where movement is not possible upon command but may
occur automatically, and
– Ideational, where purposeful movement is not possible, either automatically
or on command.
Thus patients with left hemisphere damage are more likely to present with
motor programming deficits than are patients with right hemisphere damage.
In study of motor programming differences, Light and co-workers, found support
for these conclusions and in both, involved and uninvolved arms of patients
with left CVA.
FUNCTIONAL ABILITIES
Functional ability skills following stroke are mostly impaired or absent and
differ considerably from patient to patient. In general, rolling, sitting up, transfers,
standing up and walking pose significant problems for the moderately to severely
involved patient with acute stroke. Basic ADL skills such as feeding and dressing
are also compromised. The ability to perform functional tasks is influenced
by a number of factors. Motor, sensory and perceptual impairments have the
greatest impact on functional performance, but other limiting factors include

disorientation, communication disorders, decreased cardiorespiratory endurance
and lack of motivation.
SPEECH AND LANGUAGE DISORDERS

Patients with lesions involving the parieto-occipital cortex of the dominant
hemisphere (typically, the left hemisphere) demonstrate speech and language
impairments. Aphasia is the general term used to describe an acquired
communication disorder caused by brain damage and characterized by an
impairment of language comprehension, formulation and use. Aphasia has been
estimated to occur in up to 40 percent of all stroke patients. There are many
different types of aphasias; major classification categories are fluent, nonfluent
and global.
 In fluent aphasia, speech flows smoothly, with a variety of grammatical
constructions and preserved melody of speech. Auditory comprehension is
impaired.
 In nonfluent aphasia, the flow of speech is slow and hesitant, vocabulary
is limited and syntax is impaired. Articulation may be labored. Comprehension
is good.
 Global aphasia is a severe aphasia characterized by marked impairments
of the production and comprehension of language. It is often an indication
of extensive brain damage.
 Patients with stroke may also present with Dysarthria. This term refers
to a category of motor speech disorders caused by impairment in parts
of the central or peripheral nervous system that mediate speech production.
Respiration, articulation, phonation, resonance, and/or prosody may be
affected.
 Volitional and automatic actions, for example, chewing and swallowing:
Dysphagia; and movement of the jaw and tongue may also be impaired.
In patients with stroke, dysarthria can accompany aphasia, complicating
the course of rehabilitation.
PERCEPTUAL DEFICITS
It is important to be aware of any reduction in sensory input although accurate
testing is frequently difficult. Proprioception and stereognosis is noted in addition
to superficial and deep sensation and temperature. Information about disturbance
of body image and unilateral neglect is also recorded.
There may be disturbance of awareness of parts of the body in relation

to each other or their position in space. Loss of sensation impairs the patient’s
ability to move and balance normally. In many cases, deficit can be attributed
to inattention towards the affected side rather than actual loss of feeling.
Impairment of sensation can be improved with treatment and there would
seem to be many exceptions to the traditional belief that impaired sensation
precludes functional recovery and that the loss is greater in the arm than
the leg.
Lesions of the parietal lobe of the nondominant hemisphere can produce
perceptual deficits. These are discussed in great detail in subsequent chapters.
To enumerate, these may include visuospatial distortions, disturbances in body
image and unilateral neglect. Patients with visuospatial impairments may not
be able to judge distance, size, position, rate of movement, form, or the relation
of parts to the whole. Thus, the patient may consistently bump the wheelchair
in to the door frame and is unable to get through the doorway. With topographical
disorientation, the patient consistently gets lost going from one place to another.
Patients may also experience difficulties in distinguishing figure-ground
relationships. The brakes on a wheel chair may be indistinguishable from the
rest of the parts of the wheelchair. Problems in the perception of verticality,
especially in dimly lit areas, may also occur. This may be manifested by a
patient who is constantly leaning over to one side. Body scheme (a postural
model of the body and the relationship of its parts) and body image (a visual
and mental image of one’s body) may be distorted. Patients, with unilateral
neglect, are generally unaware of what happens on the hemiplegic side. A
severe form (anosognosia) includes frank denial of the presence or severity
of one’s disability. Sensory losses and hemianopsia frequently contribute to
this perceptual problem.
COGNITIVE AND BEHAVIORAL CHANGES

Patients with stroke differ widely in their approach to processing information
and in their behavioral styles.
 Those with left hemisphere damage (right hemiplegia) demonstrate difficulties
in processing information in a sequential, linear manner. They are frequently
described as negative, anxious and depressed. They are likely to be slower,
more cautious, uncertain and insecure. This makes them more hesitant when
performing tasks and increases the need for more frequent feedback and
support. They tend, however, to be realistic in their appraisal of their existing
problems.
 Patients with right hemisphere damage (left hemiplegia), on the other hand,
demonstrate difficulty in grasping the whole idea or the overall organization
of a pattern or activity. These patients are frequently described as indifferent,
quick and impulsive and euphoric. They tend to over stimulate their abilities
while minimizing or denying their problems. Safety is, therefore, a far greater
issue with left hemiplegia, where poor judgment is common. These patients
also require a great deal of feedback when learning a new task. The feedback
should be focused on slowing down the activity, checking each component
part and relating it to the whole task. The patient with left hemiplegia
frequently cannot attend to visuospatial cues effectively, especially in a
cluttered or crowded environment.
Cognitive deficits may exist across a wide area of function. Deficits
in orientation, attention, information, processing speed, conceptual abilities,
executive functioning, memory and learning can occur. They may be primary
impairments resulting from the stroke, or premorbid changes associated
with pathologic aging. The patient with stroke typically has a short retention
span, remembering only the first few bits of information in a series of
commands. Immediate and short-term memory is often impaired, while long
term memory remains intact. Thus, the patient cannot remember the
instructions for a new task given only 30 seconds ago but can remember
things done 30 years ago. The patient may also have difficulties in
generalizing information. Thus, information learned in one setting cannot
be transposed to other situations.
The patient with stroke may demonstrate an emotional dysregulation syndrome
termed emotional lability. It is characterized by pathologic laughing and weeping
in which the patient changes quickly from laughing to crying with only slight
provocation. Such a patient is typically unable to inhibit the expression of
spontaneous emotions. Frequent crying may also accompany depression.
Thalamic lesions are usually responsible for the same.
Sensory losses coupled with an unfamiliar hospital environment and inactivity
following acute stroke can lead symptoms of sensory deprivation such as
irritability, confusion, restlessness and sometimes psychosis, delusions, or
hallucinations. Night time may be particularly problematic. Positioning the
bed with the affected side towards the door, limits social interaction and may
increase the patient’s disorientation. Some patients with diminished capacity
are equally unable to deal with a sensory overload, produced by too much
stimulation. Altered arousal levels are implicated. Sometimes, as in cases with
the hemineglect, the problem manifolds as there are diminished sensory inputs
from the affected side.
Dementia can result from multiple infarcts of the brain, termed multi infarct
dementia. It is characterized by a generalized decline in higher brain functions
and typified by faulty judgments, impaired consciousness, poor memory,
diminished communication and behavioral or mood alterations. These changes
are often associated with episodes of cerebral ischemia, focal neurologic signs,
and hypertension. The patient may fluctuate between periods of impaired function
and periods of improved or normal function.
Epileptic seizures occur in a small percentage of stroke patients and are
slightly more common in occlusive carotid disease than in MCA disease. Seizures
also occur at the onset of cerebral hemorrhage in about 15% cases. They
tend to be of the partial motor type and in some patients may occur as the
initial presenting symptom. Convulsions during the recovery stages disturb
the patient as most of them feel that there is a re-stroke. Weakness in the
muscles and deterioration of the functions for a period of few hours to few
weeks is also common.
BLADDER AND BOWEL DYSFUNCTION

Urinary incontinence may require the temporary use of an indwelling catheter.
Generally, this problem improves quickly. Early removal of a catheter is desirable
to prevent the development of infection. Patients are frequently impacted and
may require stool softeners and low residue diets to resolve this problem.
Bladder and bowel functions tend to improve with the improvement in overall
general awareness.
OROFACIAL DYSFUNCTION
Swallowing dysfunction, dysphagia, is a common complication after stoke.
It occurs in lesions affecting the medullary brainstem (cranial nerves 9 and
10) as well as in acute hemispheric lesions. In patients referred for detailed
evaluation of dysphagia, the most frequent problem seen is delayed triggering
of the swallowing reflex followed by reduced pharyngeal peristalsis and reduced
lingual control. Poor jaw and lip closure, altered sensation, impaired head
control and poor swallowing difficulties can be seen. Most demonstrate multiple
problems that result in drooling, difficulty ingesting food, aspiration, dysarthria,
and asymmetry of the muscles of facial expression. Decreased nutritional intake
may require the temporary use of a nasogastric tube for feeding. These problems
have tremendous social implications, for the patient frequently feels humiliated
and frustrated by their presence.
PATTERNS OF BEHAVIOR IN RIGHT AND

LEFT BRAIN
See Table 5.3.
TABLE Patterns of behavior in right and left brain

5.3
Behavior Left hemisphere Right hemisphere
Cognitive style Processing information Processing information in a
in a sequential, linear simultaneous, holistic, or
manner observing and gestalt manner
analyzing details Grasping overall organization
or pattern
Perception/ Processing and producing Processing nonverbal stimuli
cognition language Visual–spatial perception
Drawing inferences,
synthesizing information
Academic skills Reading: sound-symbol Mathematical reasoning and
relationships, word judgment
recognition, reading Alignment of numerals in
comprehension calculations
Performing mathematical
calculations
Motor Sequencing movements Sustaining a movement or
Performing movements posture
and gestures to command
Emotions Expression of positive Expression of negative
emotions emotions
Perception of emotion
SECONDARY IMPAIRMENTS
Psychological Problems
The patient who has had a stroke is often frustrated by changes in the ability
to sense, move, communicate, think, or act as he or she did before. Non
acceptance of the present condition is the prime reason for the same. Common
psychologic reactions include anxiety, depression, or denial. Additionally,
the patient’s behavior may be influenced by cognitive deficits that leave
him or her irritable, inflexible, hypercritical, impatient, impulsive, apathetic,
or over dependent on others. These behaviors along with a poor social
perception of one’s self and environment may lead to increasing isolation
and stress. Depression is extremely common, occurring in about one third

of the cases. Most patients remain significantly depressed for many months,
with an average time of 7 to 8 months. The period from six months to
2 years after CVA is the most likely time for depression to occur. Depression
occurs in both mildly and severely involved patients and thus, is not
significantly related to the degree of impairment. Patients with lesions of
the left hemisphere may experience more frequent and more severe depression
than patients with right hemisphere or brain stem strokes. These findings
suggest that post-stroke depression may not be simply a result of psychological
reaction to disability but rather a primary impairment directly related to
the CVA.
Decrease in Range of Movement, Contracture and Deformity

Decrease in range of movement (ROM), contracture and deformity may result
from loss of voluntary movements and immobilization. Flexibility of connective
tissue is lost and muscles experience disuse atrophy. As contractures progress,
edema and pain may develop and further restrict attempts to gain motion.
In the upper extremity, limitations in shoulder motions are common. Patients
also frequently develop contractures of the elbow, wrist and finger flexors,
and forearm pronators. In the lower extremity, plantar flexion contractures
are common. Alterations in alignment coupled with decreased efficiency of
muscles may lead to increased energy expenditure, altered patterns of movement
and excessive effort.
Deep Venous Thrombosis

Deep venous thrombosis (DVT) and pulmonary embolism are potential
complications for all immobilized patients. Common symptoms of DVT include
calf pain or tenderness, calf pain, swelling and discoloration of the leg. About
50% of the cases do not present with clinically detectable symptoms and can
be identified by Doppler or other noninvasive techniques. Anti-coagulants and
anti-platelet agents are the primary medical treatments, along with bed rest,
graded and guarded mobilization and elevation of the affected limb.
Pain
Patients with lesions affecting the thalamus may initially experience a contra-
lateral sensory loss. After several weeks or months, this may be replaced by
a severe burning pain, generalized on the hemiplegic side (thalamic syndrome).
Pain is increased by stimuli or contact with that side. Thalamic syndrome
is extremely debilitating and the patient generally has a poor functional outcome.
Pain may also result from muscle imbalances, improper movement patterns,
musculoskeletal strain, osteoporosis and poor alignment. For example, knee
pain is a common finding with prolonged or severe hyperextension during
gait. The sequelae of pain are reduced function, impaired concentration,
depression and decreased rehabilitation potential.
Shoulder Dysfunction
Shoulder subluxation and pain
Shoulder pain is extremely common following stroke, occurring in 70 to 84
percent of patients. Pain is typically present with movement and, in more
severe cases, at rest. Several causes of shoulder pain have been widely proposed.
In the flaccid stage, proprioceptive impairment, lack of tone and muscle paralysis,
reduce the support and normal seating action of the rotator cuff muscles,
particularly the supraspinatus. The ligaments and capsule, thus, become the
shoulder’s sole support. The normal orientation of the glenoid fossa is upward,
outward and forward, so that it keeps the superior capsule taut and stabilizes
the humerus mechanically. Any abduction or forward flexion of the humerus,
or scapular depression and downward rotation reduces this stabilization and
causes the humerus to sublux. Initially, the subluxation is not painful, but
mechanical stresses resulting from traction and gravitational forces produce
persistent malalignment. Glenohumeral friction-compression stresses also occur
between the humeral head and superior soft tissues during flexion or abduction
movements in the absence of normal simultaneous rotation of the arm and
normal scapulohumeral rhythm. In the spastic stage, abnormal muscle tone
contributes to subluxation and restricted movement. Secondary tightness in
ligaments, tendons and joint capsule quickly develops. Adhesive capsulitis
is a common finding. Poor handling and positioning of the hemiplegic arm
have also been implicated in producing joint micro-trauma and pain. Activities
that traumatize the shoulder include passive range of motion (PROM) without
adequate mobilization of the scapula pulling on the arm during a transfer,
or using reciprocal pulleys.
Pain develops in a typical pattern. Patients at first report sharp end-range
pain with movement and can easily pinpoint the location of the pain. If the
causative factors are not addressed, pain increases to include pain on all
movement, particularly with shoulder flexion and abduction. Increasing pain
may also be experienced in certain positions, for example, lying in bed at
night. Eventually, the patient complains of intense pain and does not tolerate
any movement of the arm. At this point, the pain is diffuse and not easily
localized. Pain may extend in to arm and hand. Long standing cases may
also have osteoporosis in the humeral head.
Reflex Sympathetic Dystrophy

Reflex sympathetic dystrophy (RSD) also occurs in approximately 12 to 25%
of the cases. The patient experiences swelling and tenderness of the hand
and fingers along with shoulder pain. Elbow joint is usually spared. Sympathetic
vasomotor changes are evident and include warm, red and glossy skin. Trophic
changes of the finger nails develop. The patient experiences increasing pain
with movement and further immobilization leads to increased stiffness,
contracture and atrophy of muscle. In the late stages, the skin is typically
cool, cyanotic and damp. The hand typically contracted in metacarpophalangeal
(MP) extension and interphalangeal (IP) flexion, similar to the “intrinsic minus
hand”. There is marked atrophy of thenar and hypothenar muscles with flattening
of the hand. Osteoporotic changes become evident on radiographs. Early
diagnosis and treatment are critical in preventing or minimizing the late changes
of RSD. Because of close daily contact with the patient, the therapist is frequently
one of the first to recognize and report early signs and symptoms. Radionuclide
bone scans can be used to reliably confirm early symptoms of RSD. Many
times, the patient’s symptoms progress up to the entire arm and hence, all
the movements of the entire upper extremity become painful and restricted.
When this is coupled with the thalamic pain syndrome, the condition takes
a long time to recover.
Deconditioning
Patients who suffer a stroke as a result of cardiac disease may demonstrate
impaired cardiac output, cardiac decompensation and serious rhythm disorders.
If these problems persist, they can directly alter cerebral perfusion and produce
additional focal signs (e.g., mental confusion). Cardiac limitations in exercise
tolerance may restrict the patient’s rehabilitation potential and require diligent
monitoring and careful exercise prescription by the physical therapist.
Deconditioning is a common finding in older adults with limited activity levels
and may have been present prior to the stroke. Age related changes in the
cardiorespiratory systems and musculoskeletal systems all affect activity tolerance
and endurance levels. Prolonged bed rest during the acute stroke phase further
diminishes rehabilitation potential, decreases energy reserves and increases
activity intolerance. Activity tolerance may also be related to depression, a
common finding in stroke.
RECOVERY FROM STROKE

Mortality for initial strokes varies considerably with an overall rate ranging
from 22 to 37% at 3 weeks to 1 month, 25 to 50% at one year, and 68
to 72% at 5 years. At ten years, only 35% of patients are still alive. The
type of stroke is significant in determining survival. Patients with intra-cerebral
hemorrhage account for the largest number of deaths following an acute episode
flowed by subarachnoid hemorrhage and thrombo-emobolic stroke. Survival
rates are dramatically lessened by a number of medical conditions and
comorbities, including age, hypertension, heart disease and diabetes. Loss of
consciousness at stroke onset, lesion size, persistent severe hemiplegia, multiple
neurologic deficits and history of previous stroke are also important predictors
of mortality. Most patients suffer recurrent episodes of stroke, usually of the
same type and these are influenced by the same risk factors influencing survival.
Recovery from stoke is fastest in the first few weeks after onset, with
most measurable neurologic recovery occurring in the first three months. Patients
may continue to make functional gains for longer periods, up to six months
or a year after insult. A few patients may demonstrate remarkable and unexpected
recovery with improvements occurring over a period of years. Rates of
improvement will vary across management categories: patients suffering minor
stroke may rapidly recover with few or no residual deficits, while patients
with severe stroke may demonstrate limited recovery. An important finding
is that recovery has been demonstrated even in patients with extensive central
nervous system (CNS) damage and advanced age due to a process called
neuroplasticity. So it becomes a general unwritten rule for the rehabilitation
specialist to try and try till the full functional recovery.
Early recovery is generally thought to be result of resolution of local vascular
and metabolic factors. Thus the reduction of edema, absorption of damaged
tissue and improved local circulation allows intact neurons that were previously
inhibited to regain function. Central nervous system plasticity is thought to
account for continuing recovery. In the presence of cell death, functional
reorganization of the CNS may occur. A number of different mechanisms have
been identified, including collateral sprouting and unmasking. Sprouting involves
synaptic reclamation of a denervated region by nearby intact neurons. Unmasking
refers to the release of previously inactive neurons, which then take over
function of the damaged neurons. These processes are thought to occur both
locally and at brain areas remote from the lesion. The redevelopment of adequate
CNS inhibitory mechanisms may underline the emergence of selective movement
control inhibition mass movements and pathologic reflexes. Results from animal
studies also suggest that environment plays an important part in recovery.
Brain injured rats raised in “enriched conditions” did considerable better than
rats raised in “impoverished conditions”.
Essentials of Assessment 77
C H A P T E R
6
Essentials of Assessment
PHYSICAL THERAPY ASSESSMENT

A thorough assessment of each patient’s problems is essential if the treatment
is to be successful. The therapist needs to observe the patient closely while
he moves against gravity and performs but also in other instance which occur
during his daily life. At first, these may be only in and around his bed, but
later it will be mandatory to observe how he moves when he walks outside,
is confronted by other people, climbs the stairs or sits down to eat. Observation
alone does not provide sufficient information as to why the patient has difficulties.
The therapist needs to feel the difficulties as well. Therapist must use one’s
hands to feel muscle tone and the resistance it offers, while the patient is
moving. With the hands one can feel the ease with which he transfers his
weight and maintains his balance. To understand what is observed and felt,
the therapist needs to remember that
the inability to move normally is due
to disturbed tone and reciprocal
innervations, not to actual muscle
weakness. That is the reason why
physiotherapy is considered a
combination of art and science by
many. A physiotherapist requires
scientific mind to diagnose the
problem and treat it and an artistic
mind to understand the requirements
of the patient and designing the
approach and the techniques of the
treatment (Figure 6.1). FIGURE 6.1: Physical therapy assessment
Assessment is continuous process as even during one therapy session, changes

will occur and treatment must be adjusted accordingly. When assessing the
problems, the therapist is constantly comparing the way in which the patient
moves to the way in which the same movement would normally be performed.
In the treatment, the therapist will try to facilitate normal patterns of movement.
It is essential that there is knowledge of how each movement sequence should
be carried out and how balance is maintained.
The physical therapy assessment will be determined by each patient’s unique
needs and problems. Comprehensive assessment of the patient with neurologic
impairments may include entire physical assessment, assessment of the higher
brain functions, assessment of the functional status of the body parts, assessment
of the synergistic patterns and associated reactions, in detail. Physiotherapy
and assessment usually go hand in hand and the therapist would constantly
assess, treat and modify the treatment strategy, whenever and wherever applicable.
Mental Status
It is important to assess cognitive function first, since it may affect the results
of other assessments. An evaluation of level of consciousness, memory
(immediate recall, short- and long-term), orientation (to person, place, time),
ability to follow instructions (one, two and three level commands), higher
cortical functions (calculation ability, abstract reasoning) and attention span
should be included, as well as an investigation of behavioral and emotional
responses. Learning deficits including retention and generalization deficits can
significantly impede rehabilitation efforts and should be identified early.
Communication Ability
Communication deficits severely limit the validity of other assessments; patient
comprehension should be fully ascertained before proceeding with these
evaluations. Close collaboration with the speech pathologist will be important
in making an accurate determination of the patient’s communication deficits.
Impairments in receptive language (word recognition, auditory comprehension,
reading comprehension) and/or expressive language function (word finding,
fluency, writing and spelling) should be noted. Education of the staff members
in communication with the patient would ensure a smooth understanding between
the two parties and misunderstanding created by taking to understand the patient
would be minimized. A quick assessment to check an individual’s level of
understanding can be performed by saying one thing to the patient and gesturing
another (e.g. “it’s not here” and putting on a shirt). The functional deficits
of dysarthria and dysphagia should be carefully examined. Alternated forms
of communication should be well-established before additional testing begins.

Help from the immediate family members can be taken if needed.
Common Assessment Format (Table 6.1)
TABLE Assessment for neurologically impaired patients

6.1
• Demographic information
• History
• Patient’s chief complaint
• Mental status
• Communication ability
• Sensation
• Perception
• Joint mobility
– Range of motion(ROM)
– Joint play
– Soft tissue compliance
• Joint stability
• Skin condition
• Edema
• Motor control
– Muscle tone
– Reflexes/reactions
– Strength
– Voluntary movement patterns
– Coordination
– Balance
• Functional mobility skills
– Bed mobility
– Transfers
– Wheelchair
– Gait
• Endurance/cardiorespiratory status
• Discharge planning
– Environmental assessment
– Equipment needs
Sensation
A sensory examination should include superficial, proprioceptive and combined
sensations. Deficits may be apparent in one sensory modality and not in others.
Differences can also be expected between the hemiplegic extremities.
Comparisons with the intact side can be made, but the therapist should be
cognizant that deficits may exist in the supposedly “normal” extremities
secondary to effects of comorbid conditions or aging. The visual system should
be carefully investigated, including tests for acuity, peripheral vision, depth
perception, and hemianopsia. Hearing status should be determined.
Perception
Significant information on sensory and perceptual deficits will be provided
by close collaboration with the occupational therapist. Many tests and formalized
test batteries have been developed to assess body scheme, body image, spatial
relations, agnosia, and apraxia. Since the patient with left hemiplegia may
behave in ways which overestimate this patient’s ability to perform, whereas
verbal cues (either the therapist’s or the patient’s) may permit success. Carefully
structuring the environment will also improve patient performance (Discussed
in detail in subsequent chapters).
Joint Mobility
An assessment of joint mobility should include an evaluation of range of
motion (ROM), joint play, and soft-tissue compliance. Problems with spasticity
may result in inconsistent ROM findings, since alterations in tone may exist
from one testing session to the next. Thus tonal abnormalities should be noted
at the time of examination. Active ROM tests may be invalid since synergy
dominance may influence performance and preclude movement in standard
active range of motion (AROM) tests. Fixed contracture and developing
deformity should be carefully documented. Passive range of motion (PROM)
tests should be also performed to check the joint stiffness or contractures
of muscles and other soft tissues. All the movements must be checked firstly
in lying for the ease of the patient as he or she would feel fully supported
and the tone of the muscles would be minimum. Secondly, the same assessment
should be carried out in functional position also and the difference between
the two should be aptly noted, the reason being, the synergistic patterns are
position and velocity dependent and any assessment in a single layer would
prove to be misleading. Goniometric assessment is done where applicable and
any change in the ROM is noted after comparing to the ‘normal side’.
Motor Control
Motor control assessment is a qualitative assessment in case of hemiplegia
and hence any attempt to quantify creates a vague picture of the patient’s
condition. Also, if the assessment is carried out qualitatively, taking into

consideration the overall motor ability, the treatment planning would be obvious
to a clinical practitioner.
Voluntary movement patterns should be examined for synergy dominance
and selective movement control (in synergy or out of synergy). Those movements
with selective control should be examined closely for coordination and timing
deficits. Strength should be examined. In the early recovery stages, traditional
manual muscle tests may be invalid in the presence of significant problems
of spasticity, reflex, and synergy dominance. An estimation of strength can
alternately be made from observation of performance during functional tasks.
An assessment of the strength of key muscles for upper extremity function
and lower extremity function (hip flexion, knee extension, ankle dorsiflexion)
has been weighted to yield a motoricity index score. This index can be rapidly
administered and has proved to be reliable in assessing motor impairment
after stroke. The examination should also include an investigation of motor
planning abilities, postural control and balance.
Specific hemiplegic assessments tools like that of Brunnstrom and Bobath
have been developed that are adapted. The Brunnstrom assessment is based
upon sequential recovery stages, and carefully plots the emergence, dominance,
and variation of the motion synergies. Both synergy and isolated movements
are assessed in terms of the active ROM completed. Gross sensory changes
and tone alterations associated with specific stages of recovery are also
determined. Later-stage control is assessed by timed tasks in which the patient
is asked to complete test items as quickly as possible. This test also presents
a quantitative analysis of hand function and lower extremity control in sitting,
standing and walking.
Fugl-Meyer and co-workers expanded on the work of Brunnstrom to develop
the Fugl-Meyer assessment (FMA) of physical performance. They used many
of the Brunnstrom test items organized in to five sequential recovery stages.
Their test improvements consisted of the development of a three point ordinal
scale with grades ranging from 0 (item cannot be performed) to 2 (item can
be fully performed). Specific subtests with subtest scores are available. The
cumulative test score for all components is 226.
The Bobath assessment is based upon a qualitative assessment of postural
and movement patterns in early, middle, or late recovery stages. Tonal
abnormalities are assessed during both passive and active movements. The
therapist may place the limbs in various positions and observe the patient’s
responses during attempts to hold the position. Tests for active movements
are divided in to two groups: advanced movement combinations progressing
from easiest to most difficult, and tests for balance and/or automatic postural
responses. Individual assessment items can also be used as a basis for treatment
using this approach since they represent an advanced recovery progression.
Since, the central state and general function of patients may vary considerably
from one treatment session to the next, frequent reassessments are recommended.
The motor assessment scale (MAS) was developed by Carr and Shepherd
to measure functional capabilities of the patient with stroke. This scale uses
eight items of motor function, including movement transitions, balanced sitting,
walking, upper-arm function, hand function and advanced hand function. The
ninth item evaluates general tonus. Each item is scored on a seven-point scale.
The scale has been shown highly reliable (r = 0.87–1.0) with high concurrent
validity. Please refer to the chapter of scales and scores for a variety of
assessment batteries.
Videography, nowadays, is a cheap and effective tool for recording the
observations initially and later to compare the outcome of rehabilitation.
Gait
Gait is usually altered following stroke, due to a number of factors, including
impairments in sensation and perception and motor control. Some of the
common problems in hemiplegic gait and their causes are shown in the
Table 6.2.
Assessment of gait may be done using a subjective rating system and/or
objective measures. Individual rating systems may bias the examiner to identify
problems in specific areas. For example, the Brunnstrom form assesses
independence from synergies, based on a normal recovery sequence; the Bobath
assessment stresses qualitative control and balance reactions; while the Barthel
index stresses functional independence and endurance. The accuracy of rating
scales for observational gait analysis is highly dependent upon the skill of
the examiner and the consistency and endurance of the patient; these latter
may be limited following a stroke. Videography, which allows the permanent
recording of gait pattern is currently the best tool for analyzing the minor
nuances of the gait. The therapist can then replay the tape and re-examine
gait deficits without tiring the patient.
Functional Assessment
At varying stages of recovery, functional mobility skills (bed mobility, movement
transitions, transfers, locomotion, stairs), basic ADL skills (feeding, hygiene,
dressing) and instrumental ADL skills (communication, home chores) should
be carefully assessed. Functional testing frequently serves to evaluate outcomes
of stroke rehabilitation and determine long-term placement. The Barthel index
TABLE Gait analysis format

6.2
STANCE PHASE
• Trunk/pelvis
– Unawareness of affected side: Poor proprioception
– Forward trunk: Weak hip extension
– Flexion contracture
• Hip
– Poor hip position: Poor proprioception
– Trendelenburg limp: Weak abductors
• Knee
– Flexion during forward progression
– Flexion contracture combined with weak knee extensors and/or poor
proprioception
• Ankle dorsiflexion range past neutral, combined with weak hip and knee
extension or poor proprioception at knee and ankle
– Weakness in extension pattern or in selective pattern or in selective motion
of hip and knee extensors and plantar flexors
– Slow contraction of knee extensors/knee remains flexed 20°–30° during
forward progression
– Plantar flexion contracture past 90 degrees
– Impaired proprioception: Knee wobbles or snaps back in to recurvatum
– Severe spasticity in quadriceps
– Weak knee extensors: Compensatory locking of knee in hyperextension
• Ankle/foot
– Equinus gait (heel does not touch the ground); spasticity or contractures
of gastroc-soleus
– Varus foot (patient bears weight on the lateral surface of the foot):
Hyperactive or spastic anterior tibialis, post tibialis, toe flexors and soleus
– Unequal step lengths: Hammer toes caused by spastic toe flexors prevent
the patient from stepping forward onto the opposite foot because of pain/
weight-bearing on flexed toes
– Lack of dorsiflexion range on the affected side (approximately 10 degrees
is needed)
SWING PHASE
• Trunk/pelvis
– Insufficient forward pelvic rotation (pelvic retraction): Weak abdominal
muscles
– Inclination to sound side for foot clearance: Weakness of flexor muscles
• Hip
– Inadequate flexion
– Weak hip flexors, poor proprioception, spastic quadriceps, abdominal
weakness, hip abductor weakness of opposite side
Contd...
Contd...
– Abnormal substitutions include circumduction, external rotation/adduction,

backward leaning of trunk/dragging toes; momentum uncontrolled swing
– Exaggerated hip flexion: Strong flexor synergy
• Knee
– Inadequate knee flexion
– Inadequate hip flexion and poor foot clearance; spastic quadriceps
– Exaggerated but delayed knee flexion: Strong flexor synergy
– Inadequate knee extension at weight acceptance: Spastic hamstring or
sustained total flexor pattern
– Weak knee extensors or poor proprioception
• Ankle/foot
– Persistent equinus and/or equinovarus: Plantar flexor contracture or
spasticity; weak dorsi flexors, delayed contraction of dorsi flexors/toes drag
during midswing
– Varus: Spastic anterior tibialis, weak peroneals and toe extensors
– Equinovarus: Spasticity of post-tibialis and/or gastroc-soleus
– Exaggerated dorsiflexion: Strong flexor synergy pattern
is one of the more reliable and widely used scales to measure stroke outcomes.
Granger et al. reported that score of 60 out of possible 100 was pivotal in
determining the attainment of assisted independence. Patients with stroke having
scores below this level, demonstrated marked dependence, while scores below
40 demonstrated severe dependence. These patients typically had longer
rehabilitation stays and were less likely to have successful outcomes. Outcome
studies using other functional scales (e.g., the functional independence measure
or FIM) are also available. All the functional scores can be individualized
for a specific patient and the nature of his environment at home and at the
workplace according to the socioeconomic conditions and patient’s needs and
preferences. For clinical implications, customized assessment for functional
aspect is strongly advocated rather than following preprogrammed scores which
are not very useful in India.
ASSESSMENT OF NORMAL POSTURAL

REFLEX MECHANISM
To assess and treat the problems of the hemiplegic patients, the factors underlying
normal movement must be understood. The normal postural reflex mechanism
which provides a background for movement has two types of automatic reaction:
righting reactions and equilibrium reactions.
A B
FIGURES 6.2A AND B: Standing posture from behind, right hemiplegia
 Righting reactions allow the normal position of the head in space and in
relation to the body and normal alignment of trunk and limbs (Bobath,
1978). They give the rotation within the body axis which is necessary for
most activities (Figures 6.2A and B).
 Equilibrium reactions maintain and regain balance. More complex than the
righting reaction, they may be either visible movements or invisible change
of tone against gravity. Basic patterns of movement evolve from the righting
reaction of early childhood, which later become interacted with the equilibrium
reaction. (Fiorentino, 1981).
The brain is continuously receiving sensory impulses from the periphery,
is informing it of the body’s activities. All movement is in response to these
sensory stimuli and is monitored by proprioceptors (in muscles and joints),
exteroceptors (in skin and subcutaneous tissue) and telereceptors (the eyes
and ears); without sensation human beings do not know how to move or
how to react to various situations, but in the conscious state intention may
govern these reactions. Normal function of the body depends on the efficiency
of the central nervous system as an organ of integration. Every skilled movement
depends on:
Normal Postural Tone

Postural tone, which is variable, provides the background on which movement
is based and is controlled at a subcortical level. It must be high enough to
resist gravity yet still permit movement. Hypertonia is loss of dynamic tone,
giving stability without mobility. Hypertonia precludes the stable posture
necessary for movement. With each movement, posture changes and cannot
be separated from it.
Normal Reciprocal Innervation

Reciprocal Innervations allows action between agonists and antagonists (Bobath,
1974). Proximally, the interaction results in a degree of co-contraction which
provides fixation and stability. Distally, skilled movements are made possible
by a greater degree of reciprocal inhibition.
Normal Patterns of Movement

Movement takes place in the patterns that are common to all although there
are slight variations in the way different people perform the same activity.
Normally, the brain is not aware of individual muscles, only of patterns of
movement produced by the interaction of groups of muscles. This is Sherrington’s
principle.
SHORT ASSESSMENT AND TREATMENT

PLANNING FOR ADULT HEMIPLEGIA
(BOBATH ASSESSMENT FORM)
PATIENT’S NAME:
ADDRESS:
DIAGNOSIS:
DATE OF ONSET:
 General impression of patient:

Seemingly younger or older than chronological age. Cooperation, indifference,
emotional release, depression, negativism, aggression, euphoria, instability
 State of health:
(How careful one has to be). Hypertension; heart insufficiency; respiration,
giddiness, weakness, etc.
 What can the patient do?
Does she use her trunk for balance? Does she use her normal side for
every activity?
Could she function with less compensation?
 What can she not do?
Does she really need a tripod? An elbow crutch? A stick? A brace? A
sling?
Could she learn to walk with or even without an ordinary walking stick?
With or without a brace?
 Is there potential on the affected side? Arm? Hand? Leg? Foot?
 Is she still within the period of spontaneous recovery?
 How is her balance in:
Sitting:
Standing:
Walking:
 Can she use her affected arm?
 Her affected hand?
 Has she got associated reactions?
 Can she speak?
 Does she understand language?
 Can she read or write?
 The sensory state:
(This is very important because of the effect of sensory deficit on movement,
muscle power and prognosis)
To test:
Deep sensation (proprioception): of arm and leg. Position sense. Appreciation
of movement (Both to be tested separately)
Arm:
Leg:
Tactile sensation: On arm and leg. Discrimination of light touch. Pressure,
stereognosis, temperature, dermatographia.
 Tonus
Test reactions to being moved on arm and leg. Test in supine and sitting.
Spasticity: Gives abnormal resistance or exaggerated assistance.
Flaccidity: Uncontrolled full weight of limb.
There may be a mixture of both.

Leg:
Arm:
1. What is the most important and first aim in treatment?
2. Which function should the patient be prepared for at this stage?
3. What may be your final limitations?
4. What can you make the patient do with little help?
5. What will you do in treatment?
Tests for the Quality of Movement Patterns

Patterns to be Tested
Tests for arm and shoulder girdle (to be tested separately in supine, sitting
and standing, as the result will be different in these positions.)
Grade 1
i. Can he hold extended arm in elevation after having it placed there?
With internal rotation?
With external rotation?
ii. Can he lower the extended arm from the position of elevation to the
horizontal plane and back again to elevation?
Forward-downwards?
Sideway-downwards?
iii. Can he move the extended abducted arm from the horizontal plane to
the side of his body and back again to the horizontal plane?
Grade 2
i. Can he lift his arm to touch the opposite shoulder?
With palm of hand?
With back of hand?
ii. Can he bend his elbow with his arm in elevation to touch the top of
his head?
With pronation?
With supination?
iii. Can he fold his hands behind his head with both elbows in horizontal
abduction?
With wrist flexed?
With wrist extended?
Grade 3
Can he supinate his forearm and wrist?
Without side-flexion of trunk on the affected side?
With flexed elbow and flexed fingers?
With extended elbow and extended fingers?
Can he pronate his forearm without adduction of arm at shoulder.
Can he externally rotate his extended arm?
In horizontal abduction?
By the side of his body?
In elevation.
Can he bend and extend his elbow in supination to touch the shoulder of
the same side? Starting with:
• Arm by the side of his body?
• Horizontal abduction of the arm?
Tests for Wrist and Fingers

Grade 1
Can he place his flat hand forward down on table in front?
Can he do this sideways, when sitting on plinth?
With fingers and thumb abducted?
Grade 2
Can he open his hand to grasp?
With flexed wrist?
With extended wrist?
With pronation?
With supination?
With adducted fingers and thumb?
Grade 3
Can he grasp and open his fingers again?
With flexed elbow?
With extended elbow?
With pronation?
With supination?
Can he move individual fingers?
Thumb?
Index finger?
Little finger?
2nd and 3rd finger?
Can he oppose fingers and thumb?

Thumb and index finger?
Thumb and 2nd finger?
Thumb and little finger?
Tests for Pelvis, Leg and Foot (Prone)

Grade 1
Can he bend his knee without bending his hip?
With foot in dorsiflexion?
With foot in plantar flexion?
Foot inverted?
Foot everted?
Grade 2
Can he lie with both legs externally rotated and extended, feet dorsiflexed
and everted, heels touching?
Hold position when placed?
Turn affected leg out again to touch heel of sound leg after it has been internally
rotated by therapist?
Perform internal and external rotation unaided?
Grade 3
Can he keep his heels together and touching while bending both knees to
right angle?
Affected foot inverted?
Affected foot everted?
Can he hold knee of affected leg flexed at right angle and alternately dorsiflex
and plantiflex ankle?
Foot inverted?
Foot everted?
Without moving his knee?
Tests for Pelvis, Leg and Foot (Supine)

Grade 1
Can he bend affected leg?
With sound leg flexed, foot off support?
With sound leg extended?
Without bending affected arm?
Can he bend hip and knee with foot remaining on the support from the beginning
of extension until the foot is near his pelvis?
Can he extend his leg by degrees, his foot remaining on the support?
Grade2
Can he lift his pelvis without extending his affected leg, both feet on the
support?
Can he keep his pelvis up and lift his sound leg?
Without dropping pelvis on the affected side?
Can he keep pelvis up and adduct and abduct knees?
Grade3
Can he dorsiflex his ankle?
Can he dorsiflex his toes?
With flexed leg, foot on the support?
With extended leg?
With foot inverted?
With foot everted?
Can he bend his knee when he lies near the edge of plinth, his leg over
side of plinth? (Hip extended)
Sitting Tests on Chair

Grade1
Can patient adduct and abduct affected leg, foot on ground?
Can he adduct and abduct affected leg, foot lifted off ground?
Grade 2
Can he lift affected leg and place foot on sound knee? (Without use of hand
to lift leg)
Can he draw affected foot back under chair, heel on the floor?
Can he stand up with sound foot in front of affected one? (Without use of
hand?)
Standing Tests
Grade 1
Can he stand with parallel feet, feet touching?
Grade 2
Can he stand on affected leg, lifting sound one?
Can he stand on affected leg, sound one lifted and bend and extend standing
leg?
Can he stand in position, sound leg forward with weight on it, affected leg
behind and bend knee of affected leg without taking toes off ground?
Grade 3
Can he stand in step position, weight forward on sound leg, affected leg behind
and lift foot without bending hip of affected leg?
Foot in inversion?
Foot in eversion?
Can he stand on affected leg and transfer weight over it to make step with
sound leg?
Forward?
Backward?
Can he stand on sound leg and make steps forwards with affected leg without
hitching pelvis up?
Can he stand on sound leg and make step backwards with affected leg without
hitching pelvis up?
Can he stand on affected leg and lift his toes?
Tests for Balance and Other Automatic Protective Reactions
Balance Reactions
 Support and balance reactions on the affected forearm or on the affected
extended arm when he lifts his sound arm and turns over from prone lying
on his side.
 Balance reactions of the trunk and legs in sitting without the use of his
sound hand, weight on the affected hip.
 Balance reactions in four-foot kneeling.
 Balance reactions in kneel-standing.
 Balance reactions in half-kneeling.
 Balance reactions in standing, feet parallel.
 Balance reactions in standing, feet in step position.
 Balance reactions on affected leg when making steps with sound leg.
 Balance reactions standing on the affected leg, the sound leg lifted.
Protective Extension and Support on Affected Arm
 In being moved forward towards table or wall.
 On being moved sideways to affected side towards table or wall.
 To protect face with affected arm and hand against ball or pillow thrown
against.
Balance Reactions
 His shoulder girdle is pushed towards affected side. Does he remain supported
on affected forearm?
 His sound arm is lifted forward and up, as when reaching out with one
hand.
Does he immediately transfer his weight towards the affected arm?
 His sound arm is lifted and moved backwards and he is turned to his side,
support on affected arm.
Does he remain supported on affected arm?
Patient sitting on the plinth, his feet would be unsupported.
 He is pushed towards the affected side. Does he stay upright?
Does he laterally flex his head towards the sound side?
Does he abduct his sound leg?
Does he use the affected forearm for support?
Does he use the affected hand for support?
 He is pushed forward.
Does he bend affected hip and knee?
Does he extend his spine?
Does he lift his head?
 Both his legs are lifted up by the therapist, knees flexed.
Does he stay upright?
Does he move affected arm forward?
Does he support himself backwards with affected arm?
Patient in four-foot kneeling
 His body is pushed towards the affected side.
Does he abduct the sound leg?
Does he remain on all fours?
 His sound arm is lifted and held up by the therapist.
Does he keep affected arm extended?
 His sound leg is lifted.
Does he keep affected leg flexed and transfer weight on to it?
 His sound arm and affected leg are lifted.
Does he keep affected arm extended?
 His affected arm and his sound leg are lifted.
Does he remain on affected flexed leg?
 His sound arm and leg are lifted.
Does he transfer his weight towards the affected side and maintain position.
Patient in kneel standing.
 He is pushed towards the affected side.
Does he abduct the sound leg?
Does he bend head laterally towards the sound side?
Does he use his affected hand for support?
 He is pushed towards the sound side.

Does he abduct the affected leg?
Does he extend the affected arm sideways?
 He is pushed backwards and asked not to sit down.
Does he extend the affected arm forwards?
 He is pushed gently forwards, his sound arm held backwards by the therapist.
Does he use affected arm and hand for support on the ground?
Does he lift affected foot off the ground?
Patient half kneeling, sound foot forwards. (He should not use sound hand
for support)
His sound foot is lifted up by the therapist.
Does he remain upright?
Does he keep affected hip extended?
 His sound foot is lifted by the therapist and placed sideways.
Does he remain upright?
Does he show balance movements with his affected arm?
 His sound foot is placed from the above position back to kneel-standing.
Does he keep upright?
Does he keep affected hip extended?
Patient standing, feet parallel, standing base narrow.
 He is tipped backwards and not allowed to make step backwards with sound
leg. (Therapist puts her foot on his sound one to prevent step.)
Does he step backwards with affected leg?
 He is tipped backwards and not allowed to make steps with either leg.
Does he dorsiflex toes of affected leg?
Big toe only?
Dorsiflex ankle and toes of affected leg?
Does he move affected arm forwards?
 He is tipped towards sound side.
Does he abduct affected leg?
Does he abduct and extend affected arm?
Does he make steps to follow with affected leg across sound leg?
Patient standing on affected leg only. (He is not allowed to use sound
hand for support.)
 His sound foot is lifted by the therapist and moved forwards as in making
a step, extending his knee.
Does he keep the heel of affected leg on the ground?
Does he keep the knee of the affected leg extended?
Does he assist weight transfer forward over affected leg?
 His sound foot is lifted by the therapist and held up while he is pushed
gently sideways towards the affected side.
Does he follow and adjust his balance, moving the foot of the affected
leg sideways by inverting and everting his foot alternately?
The same maneuver is done pulling him towards the affected side.
Does he follow and adjust his balance by moving his foot as above?
Tests for Protective Extension and Support of the Arm

When testing these reactions, the patient’s sound arm should be held by his
hand so that he cannot use it. It is advisable to hold the sound arm in extension
and external rotation because this facilitates the extension of the affected arm
and hand.
 The patient stands in front of a table or plinth. His sound arm is held
backwards, he is pushed forwards towards the table.
Does he extend his affected arm forward?
Does he support himself on his fist?
On the palm of his hand?
His thumb adducted?
His thumb abducted?
 The patient stands facing a wall, at a distance, which allows him to reach
it with his hand. He is pushed forward against the wall, his sound arm
held backwards.
Does he lift his affected arm and stretch it out against the wall?
Does he place his hand against the wall, fingers flexed, thumb adducted?
Fingers open, thumb abducted?
 The patient is sitting on the plinth. His sound arm is held sideways by
the therapist. He is pushed towards the affected side.
Does he abduct the affected arm and support himself on his forearm?
On his extended arm?
Does he support himself on his fist?
On his open palm?
Thumb and fingers adducted?
Thumb and fingers abducted?
 The patient stands sideways to a wall, at a distance which allows him
to reach it with his affected hand.
Does he abduct and lift the affected arm?
With flexed elbow?
Does he reach out for the wall with extended elbow?
With his open hand?
With adducted thumb and fingers?
With abducted thumb and fingers?
 The patient lies on the floor on his back. His sound hand is placed under
his hip so that he cannot use it. The therapist takes a pillow and pretends
to throw it towards his head.
Does he move his affected arm to protect his face?
With flexed elbow?
With fisted hand?
With open hand?
Can he catch the pillow?
SUMMARY
The foregoing suggested tests should be used during treatment as well as
for the initial assessment of the patient’s need. They are not intended to be
used as a test battery on every patient, one test after another before treatment
is begun. Testing in this way gives the therapist not only constant information
about the patient’s ability and disability and about improvement achieved or
not achieved, but it also gives a guide for necessary changes of treatment
and for the way in which treatment should be progressed.
The importance of a closed link between assessment and treatment has
been presented, together with three groups of detailed tests specifically designed
to assist the hemiplegic patient’s motor patterns. The results of the test will
give the therapist a guide to the planning of treatment and information about
patient’s recovery.
While treating a patient having hemiplegia, the physiotherapist should always
be focused on the assessment of the condition rather than the prototype exercise
program. The treatment is never commenced before a thorough and stringent
assessment protocol. The assessment comprises of the evaluation of the physical,
mental, medical, emotional, social and other aspects which affect a person,
as required and all these parameters are used in designing the ‘exercise program’
for the patient. The assessment and the treatment always go parallel to each
other and an experienced physiotherapist would agree that all the treatment
or therapy sessions are truly assessment sessions and vice versa. If a detailed
and dedicated attempt is made towards the evaluation, the treatment program
becomes evident and self-revealing. For the beginners, it is recommended that
all the evaluation parameters should be written down and hence, it would
become easier to design a perfect program for the patient. An experienced
mind will gel both the assessment and therapy sessions with ease and hence,
a lot of time saving on the part of the patient as well as the therapist is
saved and the sessions become more effective.
Many scientists and clinicians of repute have taken great pains to divide
the total recovery of the hemiplegic patient in to sequences as described before.
A working knowledge of all these stages is recommended for an overview
of the progression of the patient’s condition.
C H A P T E R
7
Management and
Rehabilitation Medicine
MEDICAL MANAGEMENT
Medical management includes the identification and control of risk factors.
Primary prevention strategies may include:
 Regulation of blood pressure
 Dietary adjustments: Reduced intake of saturated fats and control of
hypercholesterolemia and sodium and potassium intakes
 Cessation of smoking
 Platelet-inhibiting therapy: Use of platelet anti-aggregates, or anticoagulants
 Control of associated diseases (e.g. diabetes, heart disease)
 Surgery (carotid or vertebrobasilar endarterectomy, angioplasty)
 Spasticity management
 Critical care management in early stages
 Control of the complications and their management.
Medical management of acute cerebral infarction and progressing stroke generally
includes strategies to:
 Restore fluid and electrolyte balance
 Maintain adequate airway and pulmonary function.
Patients in the acute stage may require suctioning but rarely intubation
or assisted ventilation. Oxygen therapy may improve clinical signs of hypoxia
but is not normally indicated.
 Maintain sufficient cardiac output. If the causes of stroke are cardiac in
origin, medical management focuses on control of arrhythmias and cardiac
decomposition
 Prevent hypoxia and control blood pressure. Hypotension is managed with
volume expanders. Hypertension agents may be used but have the added
risk of inducing hypotension and decreasing cerebral perfusion
Management and Rehabilitation Medicine 99
 Prevent hypoglycemia or hyperglycemia

 Control seizures and infections
 Control intracranial pressure and uncal herniation using antiedema agents.
Ventriculostomy may be indicated to monitor and drain cerebrospinal fluid
(CSF).
Additional strategies currently under intense investigation include:
 Administration of clot-dissolving enzymes (fibrinolysins such as tissue
plasminogen activator (TPA or streptokinase), with rapid referral to neurologic
services
 Strategies aimed at increasing cerebral perfusion (hemodilution) and
interrupting the cytotoxic chain of events (e.g., glumate receptors blockers,
calcium channel blockers, barbiturates, or naloxone).
Neurosurgery may be indicated in cases where intracranial bleeding or
compression cause elevated intracranial pressures, since death may result from
brain herniation and brainstem compression. Generally superficial or lobar
lesions (subdural hematoma, aneurysm, subarachnoid hemorrhage and
arteriovenous malformation) are more amenable to neurosurgery than large,
deep lesions.
Comprehensive services for the patient with stroke can best be provided
by a team of rehabilitation specialists including the physician, nurse, physical
therapist, occupational therapist, speech pathologist and medical social worker.
Additional disciplines may also include a neuropsychologist, audiologist,
dietician, or ophthalmologist. One of the critical aspects of communication
with team members is the development of an integrated plan of care
with collaborative goals and treatments that are mutually reinforced in all
therapies.
PHILOSOPHY OF REHABILITATION MEDICINE

Hope, acceptance of the disability, goal
setting, persistent efforts and reaching the
goal.
Rehabilitation medicine means to make
the disabled person “independent” and
“self-sufficient” in all aspects of life.
Mahatma Gandhi, the father of nation
has given many life philosophies which
are well-recognized and honored by the FIGURE 7.1: Gandhian philosophy of
people all over the world. The philosophy vocational self-sufficiency
of “self-sufficiency” and “independence” is the prime focus of the rehabilitation

medicine professionals (Figure 7.1).
Need of Rehabilitation Medicine

Once the person becomes disabled (minor or major disability), the person
is dependent for his activities of daily living (communication, self-care, mobility,
feeding and earning for their livelihood). If proper measures are not taken
for the rehabilitation of these disabled, they will become a burden to themselves,
their family, society and the nation at large; hence, rehabilitation of a disabled
person is an important thing not only for the person, but for the family and
society and the nation.
Principles of Rehabilitation Medicine

Treatment
 It is a nondrug treatment program
 Natural physical agents are used for this treatment viz:
– Heat
– Cold
– Light
– Sunrays
– Electricity
– Therapeutic exercises
– Supportive and assistive gadgets
– Human support
– Mind of the patient
– Team work.
Patient is the most important person of the rehab medicine team. He is
not a passive recipient of the treatment but also an active achiever of the
goal. Rehabilitation medicine is not just restoration of the lost body functions
but the final aim is to place the disabled person back to the family and to
integrate the person in the work place and to provide a meaningful altered
life style.
The goals of medical sciences are:
 To promote health
 To preserve health
 To restore health.
These goals are embodied in the word “prevention.”

1. Primary prevention:
It can be defined as “Action taken prior to the onset of disease, which
removes the possibility that a disease will ever occur.” It can be achieved
through vaccines, hygiene, good nutritive food, cleanliness, hygiene, good
habits, balance between activity and rest, exercises and education about
potent threat to the health. The diseases and trauma are prevented and a
good health is maintained.
2. Secondary prevention:
It can be defined as “Action which halts the progress of a disease at its
incipient stage and prevents complication”. The specific interventions are
early diagnosis and adequate treatment-means treating it before irreversible
changes have taken place. The health programs initiated by the government
are at the level of secondary prevention.
3. Tertiary prevention:
It can be defined as “All measures available to reduce or limit impairments
and disabilities, minimize the sufferings caused by existing departures from
good health and to promote the patient’s adjustments to irremediable
conditions”. Once the recovery and the restoration of the lost body functions
is reached to the plateau—the disabled person is trained to maximize the
available potentials and to retrain him “For return to living” back in the
family, society and at work place by rehabilitation. Rehabilitation has been
defined as “The combined and coordinated use of medical, social, individual
to the highest possible level of functional ability.” Rehabilitation medicine
involves disciplines such as physical medicine or physiotherapy, occupational
therapy, speech therapy and audiology, psychology, special education, social
work, vocational guidance, etc.
AREAS OF REHABILITATION
The following areas of concern in rehabilitation have been identified:
 Medical rehabilitation—Restoration of lost function.
 Physical rehabilitation—Restoration of lost physical functions.
 Vocational rehabilitation—Restoration of the capacity to earn a livelihood.
 Social rehabilitation—Restoration of family and social relationships.
 Psychological rehabilitation—Restoration of personal dignity and
confidence.
 Sexual rehabilitation—Hemiplegic patients are taught and trained about
their sexual problems, sexual needs and how to find out sexual options
for the sexual gratifications and sexual rehabilitation.
ASPECTS OF REHABILITATION
Physical rehabilitation has four aspects are given below:
Institution-based Rehabilitation (IBR)

The rehabilitation measures takes place in the institution, where ideal therapy
takes place. It is provided by the high standard professionals. It is costly
to use high technology. In the institution, lots of interactive learning takes
place with other medical professionals. Medical education and research work
also takes place.
Community-based Rehabilitation (CBR)

Here, proper study and the assessment of the community are done where the
patient is going to live. The resources are found out from within the community
(i.e. persons and materials). Persons are trained by professionals and low-
cost appliances are used to help the disabled person.
Outreach-based Rehabilitation (OBR)

The rehabilitation medicine teams reach out in the community from the IBR
and provide necessary assessment, treatment and guidance through camps,
touring the patient’s area program, etc.
Community Approach to Handicap in Development

(CAHD)
Generally, the people in the society have a low level image for the disabled
person. Some of these misconceptions are that the disabled cannot perform
many tasks; he needs only custodial care and the person has to live a vegetative
life, etc. Instead of giving sympathy, these people are to be considered as
differently abled and empathy is to be provided to them, in their resettlement.
Necessary mass education is needed to be given through media, handouts
etc. to increase awareness about disability and its management and also to
provide support to the disabled by the abled ones.
IMPAIRMENT, DISABILITY AND HANDICAP

The World Health Organization’s International Classification of Impairments,
Disabilities and Handicaps (ICIDH–2) defines these terms as follows:
Impairment
Any loss or abnormality of physiological, psychological, anatomical structure
or function. Examples—loss of a finger, loss of conduction of impulse in
the heart, or loss or certain chemicals in the brain leading to Parkinsonism.
Not all impairments lead to disability, for example, loss of pinna of ear would
not lead to loss of hearing but merely results in cosmetic deficiency.
Disability
Any restriction or loss of ability to perform an activity in the manner or
within the range considered normal for a human being resulting from impairment,
for example, difficulty in walking after lower limb amputation. To be considered
disabled, a person should not be able to perform day to day activities, considered
normal for his age, sex or physique.
Handicap
A disadvantage for a given individual in his or her social context, resulting
from impairment or a disability that limits or prevents the fulfillment of a
role that is normal for that individual. Many socioeconomic factors like family
background, skills achieved and financial stability come into play while
determining handicap. Impairment is a manifestation of a problem at the tissue
or organ level, disability at the level of individual, while handicap is the
translation of the problem at the social level.
REHABILITATIVE MANAGEMENT
General Considerations
 Rehabilitation, begun early in the acute stage, optimizes the patient’s potential
for functional recovery.
 Early mobilization prevents or minimizes the harmful effects of deconditioning
and the potential for secondary impairments.
 Functional reorganization is promoted through use of the affected side.
 Maladaptive patterns of movement and poor habits may be prevented.
 Mental deterioration can be reduced through the development of a positive
outlook and an early, organized plan of care that stresses resumption of
normal, everyday activities.
 In the acute care setting, patients may be referred for rehabilitation services
or may be admitted to a specific stroke rehabilitation unit, if such a kind
of unit is functioning in the vicinity of the patient’s residence. Both groups

have consistently demonstrated significantly improved functional outcomes
when compared to patients not receiving those services.
 Patients with moderate to severe residual deficits generally require intensive
rehabilitation services to assist functional recovery. Optimal timing of
rehabilitation based upon individual patient readiness is also important
consideration.
 A number of factors appear to be related to rehabilitation readiness, including
the side of the lesion. There is some evidence to suggest that patients with
right hemiplegia may respond more favorably to earlier comprehensive
rehabilitation efforts. Patients with left hemiplegia, who suffer more cognitive
perceptual deficits and generally have longer rehabilitation stays, may benefit
from the additional preadministration time to allow for cognitive and
perceptual motor reorganization.
 Equally important factors that might influence the timing of rehabilitation
efforts include medical stability, motivation, patient endurance, stage of
recovery and ability to learn and last but not the least, the support from
the immediate family members and financial considerations.
THE REHABILITATION TEAM

 Family physician
 Neurophysician
 Neurosurgeon
 Physician-rehabilitation medicine
 Physiotherapist
 Occupational therapist
 Speech therapist and audiologist
 Orthotist and prosthetist
 Rehabilitation specialist nurses
 Clinical psychologist
 Medical social worker
 Vocational guide
 Recreational expert
 Relatives of the patient.
The role of each member of the rehabilitation team is as important as other
at different stages of the rehabilitation process. Each one of them has got
a specific, well-defined work cutout for them in an ideal condition.
Family Physician
Family physician or a family doctor as we call them in India, is the backbone
of the total medical care that the patient receives. They are the coordinators
of the overall process. The patient usually goes to the family physician on
the start of the symptoms. After carrying out primary clinical neurological
examination, the patients are then referred to the specialists. Even during patient’s
hospital stay, they communicate with the specialist and with the relatives of
the patient in a bilateral talk and become a bridge between the two. They
carry forward the same job throughout the process of rehabilitation. From
time to time, they also tackle the minor health related issues and mostly tackle
all the queries imposed by the patient and their relatives. They always address
to the psychological aspect of the patient and their immediate family. Thus,
their role in the rehabilitation is of immense value and they therefore, influence
directly on the final outcome of the patient suffering from hemiplegia. They
are the primary caretakers in the rehabilitation team along with the
neurophysicians, neurosurgeons and the physicians. In a typical Indian setup,
they are of utmost importance.
Neurophysician–Neurosurgeon
They diagnose the patient’s condition with various clinical, radiological,
pathological and other tests and come to a proper conclusion. This in turn
leads them to starting of the medical treatment through which, the patient’s
life is saved and the post disease disability is minimized. The intervention
of the other rehabilitation personals is duly prescribed by them and the entire
treatment protocol is set up. Time to time, the patient’s condition is accessed
and changes in the treatment are made if necessary. They diagnose the problem,
by integrating the information obtained from the various clinical, pathological,
radiological tests. After promptly diagnosing the problem, various treatment
programs are started immediately and the services of other professionals are
taken if required. Assessment of the condition is done by them from time
to time and the treatment is duly changed and modified.
Rehabilitation Medicine Expert

There are these kinds of professionals in some of the countries which only
deal with the rehabilitation medicine. However, in India, we do not have such
kind of professionals in most of the places. They take over from the medical
experts after the initial health and the general condition of the patient improves.
In our country, this work is jointly done by the neurophysicians and the
enlightened physiotherapists. Together as a team, they carry out the essentials

of the rehabilitation process.
Physiotherapists
Physiotherapists or the physical therapists as they are widely known in the
world today are arguably one of the most important members of the rehabilitation
team, who are gaining acceptance world over in managing the treatment of
the hemiplegic patients. They assess the physical condition of the patient and
find out the areas of concern and help in accurate physical diagnosis of the
condition of the patient. After the assessment, they plan out the therapy program
most suitable for the individual and start the program, continue it and regularly
modify the strategy of the same till the patient becomes self-sufficient,
self-reliant and independent to carry out the lifestyle of choice.
Occupational Therapists
As the name suggests, the occupational therapists are the ones who actually
prepare the patients to jump back to the vocation of the premorbid state.
With various techniques and designs, they ensure that the environment becomes
user-friendly. They work on the ergonomic level of the patient as well as
the environment. They work on the perception of the patient so that the patient
has a conducive environment for other rehabilitation members to work
upon.
Speech Therapists and Audiologists

The speech therapists assess, diagnose and treat various disorders of speech,
language and comprehension. They train them to become expressive and
communicate with the fellow men clearly.
Orthotists and Prosthetists

These are the professionals who make the artificial devices to keep the limbs
of the patient in a desired position. Along with the physiotherapists, they
design and develop a befitting device which can be worn by the patient and
which will assist profusely in speedy recovery. The splints can be either static
or dynamic in nature. The commonly used splints are enumerated below. Cock
up splint, ankle foot orthosis, knee support, shoulder subluxation strap, night
splints and pneumatic splints are few of the most useful splints. The exact
functions of these splints would be discussed in detail elsewhere.
Special Rehabilitation Nurses

As such, nursing is of paramount importance to any patient. But, the hemiplegic
patients require some special attention on the part of the nursing staff. Initially,
when the patient is totally bedridden, he will require special attention towards
the hemiplegic side. Hygiene, on the affected side, may be low if not properly
taken care of due to unwanted spastic patterns of motor activity, e.g. clenched
fist. Also, there may be a combination of hypotonia as well as hypertonia
which needs special attention while turning the patient during sponging or
toilet training. Special nurses know the importance of giving all the kind of
sensory inputs from the hemiplegic side, so that the motor response may be
adequate. Problems like subluxated shoulder joint or stiff shoulder joints can
be prevented right from the beginning by ensuring up to the mark nursing
care. Thus, the nursing staff which is trained in dealing with the neurological
patients in particular help in the speedy recovery of the patient.
Clinical Psychologists
Preparing the patient for the difficult times ahead so that the disturbed mind
of the patient does not interfere in the rehabilitation process but in fact helps
in the process, is the main aim of all the patients going through the routine
of psychological orientation program. Clinical psychologists assist them to
cope up with the real life situational problems post-hemiplegia. Not all the
patients require an intervention of a psychiatrist, most of the patients respond
well to the sessions given by the clinical psychologists. Here in India, this
work is mainly done by the relatives of the patients in accordance with almost
all the members of the rehabilitation team. This is a double-edged sword,
because unscientific input given by untrained relatives may cause more
psychological impairment rather than helping patient. Severe cases of behavioral
problems may be well-referred to the psychiatrists. Many cases require support
of the medicines like antidepressants or mood elevators.
Medical Social Worker

Medical social workers are the ones who create a social structure or framework
for the patient so that the patient can get reasonably adjusted back in the
society. We are today living in the 21st century which is very advanced society,
but, unfortunately the disability is looked down upon by the so called able
population. In such circumstances, the medical social worker will strive hard
to put the patient back to the social life once again despite of the disability
status. He will ensure that the resources which are present for the disabled,
given by either government or charitable trusts, etc., reach the patient in totality
and are used by the patient judiciously.
Vocational Guide
Not all the patients go back to the vocation of the premorbid state. They
are now differently abled and hence, may not be able to function as efficiently
as their prediseased state. That is why, they will require some other occupation
for their livelihood. The vocational guide will help to tap the patient’s potential
to a greater extent and arrange for the same.
Recreational Therapists
These types of professionals may not exist in developing nations, but in some
countries like Australia they do function in the rehabilitation hospices. They
bring the recreation and fun back into the lives of the patients. They make
the patients play games and modified sports activities. In some hospitals, these
activities are carried out by the staff of the hospital. These activities look
very simple but amazingly they are highly refreshing and energizing for the
patients. They should be incorporated into the weekly routine of the patient’s
rehabilitation program. A sense of healthy competition motivates the patients
to achieve the desired goal in a playful manner. Playing or sports of any
kind would improve the quality of the movement of the body and will facilitate
secretions from the brain which would be relaxing and mood elevating.
Relatives of the Patient

India is a country with strong traditional values and cultural ethos. Here, most
of the work of the rehabilitation is carried out by the close relatives of the
patient right from the acute condition to the final stages of the rehabilitation
program. Coordination, integration, support, nursing, recreation, vocational
guidance, carrying out exercises, all aspects of the treatment is duly carried
out by the relatives and mostly very actively and with pleasure. This is the
beauty of India and Indian culture. But, unfortunately as the country is growing
and moving towards bigger cities, the nuclear families are at an increase and
the support of the relatives is diminishing fast especially in bigger cities. In
this scenario, the coordination of the rehabilitation team is vital, as it is the
only support for the immediate family of the patient. We, as physiotherapists
routinely see that nowadays, numbers of care takers for the patient are decreasing.
The patients and the immediate family members are willing to carry out the
optimum for the recovery, but they do not get enough support. For an example,
the patient has started walking and can attend the physiotherapy department
for the treatment. But, he will require transportation and help to reach the
department. This is difficult to get and hence, the therapy is compromised.
This leads to inadequate treatment and the disability is higher and the time
of recovery is prolonged, or even, the recovery is denied.
It should be understood that providing only the facility will not ensure
that the patient is receiving it, there should be an effort for ensuring that
the patient is actually able to utilize the same.
ETHICAL VALUE SYSTEM IN PATIENT CARE

In our country, traditionally, the value system was always strong. But,
nevertheless, strong competition in all fields and depletion of resources has
forced some of the young to modify their moral values. But, in case of patient
care, if any decrease in moral standard would directly affect the outcome
of the recovery of the patient and there would be a breach in the trust between
the patient and the treatment provider. Thus, in all faith, strong value system
on both the sides would ensure a healthy environment.
C H A P T E R
8
A Systematic Approach
to Treatment
APPROACH TO TREATMENT
The Unilateral Approach
It is generally accepted today that patients who have suffered from hemiplegia
need not spend the rest of their lives in bed, but it was not so with the
traditional methods. They were directed towards gaining independence by
strengthening and training the sound side to compensate for the affected side.
Many disadvantages are inherent in such methods:
 The resultant one-sidedness accentuates the lack of sensation and awareness.
 Relying on a tetrapod or stick for balance not only increases spasticity
and abnormal associated reactions, but prevents use of the unaffected hand
for functional tasks (the hand being solely involved in maintaining the patient
in an upright position).
 One-sidedness requires increased effort to perform and function, making
movement tiring and difficult. Consequently, spasticity increases and
movement becomes more abnormally in a self-perpetuating manner.
 Progressive spasticity in the lower limb demands increasingly complex
appliances which are difficult, if not impossible, for the patient to apply
himself and which may ultimately fail to control the position of the foot.
 Increased tone in the upper limb leads to a distressingly obvious deformity,
which hinders mobility and everyday activities including washing and
dressing.
 The patient has no means of maintaining his balance or saving himself
when he falls toward the hemiplegics side or backward as the stick or
tetrapod would leave the floor, He is, therefore, very afraid walking or
moving while standing.
A Systematic Approach to Treatment 111
 Strengthening only the sound side will further accentuate the hemineglect
of the affected side and even the natural process of recovery is hindered.
 Over stimulation of the sound side along with the strengthening will produce
biomechanical faults and this ‘out of line’ posture will be hazardous to
the entire musculoskeletal system.
The Bilateral or Symmetrical Approach

 The bilateral approach is self-explaining term in which importance is given
to both the sides and the therapy is aimed to gain movements of both
the sides, which are biomechanically correct.
 Thus, this approach is also known as the symmetrical approach.
 Preferable methods stress the need to re-educate movement throughout the
body, realizing that as the quality of movement improves, function will
automatically improve.
 They aim to normalize tone and to facilitate normal movement, thus providing
the sensorimotor experience on which all learning is based. If the patients
are allowed to move in an abnormal manner with abnormal muscle tone,
such experience of movement will be all he knows and correction afterwards
will be more difficult.
 Everyone, regardless of age, should be treated in a way which gives the
opportunity to develop maximum potential (Adler et al, 1980). Even if
dramatic motor recovery is not achieved, each patient will be able to function
better and live more normally.
 For those who have not reached complete independence, at least they will
feel safer and move more freely and therefore will be easier to help.
 All treatment should be directed towards obtaining symmetry with normal
balance reactions throughout the body.
 The affected side should be bombarded with every form of stimulation
possible to make the patient aware of himself as a whole person again.
 Re-education of bilateral righting and equilibrium reactions in the head
and trunk are vital for regaining independent balance. Importance of the
trunk, as a base for the normal movements in space, is beyond question.
 The recovering brain will learn whatever is presented to it, just like a child
up to few years grasps even the complex concepts. Thus, right from the initial
stages of the treatment, patient is moved in normal patterns of activity.
 From the beginning, the patient must be discouraged from using the good
arm to assist every movement as this reduces stimulation of the normal
postural reflex mechanism and could prevent retune of control on the affected
side.
 The patient should never struggle to perform an activity which is too advanced
for him. Any movement he is unable to manage himself should be assisted
to make the action smooth and easy without being passive. Excess effort
induces abnormal tone and unwanted associated reactions (Brunnstrom, 1970)
 Assistance should be gradually lessened, until the patient performs the
movement unaided
 Repetition re-establishes a memory of the feeling of normal movement
 Assistance does not mean that the therapist should replace the patient’s
effort. Assistance is given only to augment the active effort on patient’s
part. Even while carrying out passive movements in initial stages, patient
is always told to produce some effort along with and in the direction of
the movement
 When and if movement returns to the limbs it will be in abnormal patterns.
It is most important to make the patient very aware of unwanted abnormal
movements or associated reactions; such stereotyped patterns must be firmly
corrected at once to prevent those becoming established habits (Kottke,
1980). It is vital to teach the patient to inhibit such reaction by self, e.g.
to learn to stop the arm flexing up or the leg shooting into extension,
each time, anything is done
 It is important that the fight against the hemiplegic posture be carried
out on a 24-hours basis and not only by the intermittent therapy session
(Ruskin, 1982). Thus, the therapy sessions do not end with the therapist
leaving the patient but he should make sure that vital information is taught
to the patient as well as the caretakers for the follow-up throughout the
day
If everyone in contact with the patient reinforces the approach from the
start, hours of physiotherapy time will be saved, easier and quicker learning
is facilitated and the final result will be far more satisfactory. Because it is
an overall management of the patient, the patient is never ‘too ill to treat.’
Let us now consider few important techniques for treating a hemiplegic
patient one by one. First let us consider the Bobath technique.
Bobath Concept for the Treatment of Adult Hemiplegia

The main concept of the treatment protocol designed by Berta Bobath is:
It is impossible to superimpose normal patterns on abnormal ones, so the
abnormal patterns must be suppressed. This is to inhibit spasticity at their
“key points” of control to change the tone and facilitate:
 As near normal patterns of posture.
 To teach specific voluntary control.
The aim of the treatment is to reduce spasticity and facilitate more selective
movement patterns both voluntary and automatic in preparation for functional
activities, maintenance of posture and balance reaction.
 Shunting: By shunting, it means that the afferent impulses from muscle
and joints influence the excitatory and inhibitory state (i.e. the synaptic
pathways) of the spinal centers of the CNS. Shunting makes it possible
to direct efferent impulses into predictable channels (the desired muscle
groups) by positioning the body parts in various shunts—synaptic chains.
 Inhibition: it is the ability to refrain from one action in favor of another.
This includes normal reaction to stimulus, i.e. the reaction in proper relation
to stimulus.
 Key points: They are the proximal body parts from which the pathological
reflex activity and the tone in the rest of the body part can be influenced.
 Reflex inhibiting pattern (RIP): Is the pattern which change or break
up the abnormal patterns due to release of tonic reflex activity.
 Facilitation: Facilitation incorporates the positioning of the patient in
preparation for the automatic or the specific voluntary movements as the
movements are easier to perform in certain postural sets.
 Tapping rationale: These techniques of tactile kinesthetic stimulation are
similar to ‘Kabat and Knott’. Recruiting and summation of nervous impulses
by careful applied “Reciprocal Stimulations” to the muscles.
– Effects:
• To produce tone, increase in tone without producing hypertonia.
• Facilitate muscular activity.
• The treatment of hemiplegia is not a series of set exercises but sequences
of learning or re-learning of movements for functional activities and
maintenance of balance.
Principles of Treatment
The problem of the treatment is not that of strengthening or relaxing individual
muscle groups but that of:
 Obtaining a more near normal muscle tone.
 Improving the coordination of posture and movements.
 A normal postural reflex mechanism is the prerequisite for normal movement.
It consists of the interaction of various postural reactions, especially the
righting and the equilibrium and balance reaction (Bobath B 1954, Bobath
K 1959). A normal background of muscle tone for movements should be
sufficiently high to make weight bearing against gravity possible and to
give fixation to the movement but it must not be so high as to interfere
with the movement. Constant changes of posture are necessary

accompaniments to the movements and changes of posture take place
automatically, before a movement is initiated. (We don’t think how we
want to take turn, sit, stand or walk; we accomplish it totally, at an automatic
level.)
Thus, every movement requires adequate postural sets to perform movements
with ease and grace. Normal postural reflex activity is a prerequisite for normal
muscle tone. Abnormal postural reflex activity is associated with abnormal
muscle tone and set postural sets. The prime aim of the treatment is to normalize
the tone by inhibiting abnormal postural reflex activity (Bobath B, 1955; Bobath
K, 1957). These patterns are called reflex inhibitory patterns (RIP). Only after
normalizing the tone at their “key points” of control (i.e. the head and neck
and trunk), can the required movement pattern be performed without effort.
Any effort will increase the tone, which will lead to abnormal reflex activity
and abnormal performance of movement.
Principle Aims
 To change the abnormal tone by incorporating reflex inhibitory patterns.
 Reeducation of the abnormal postural patterns rather than to aim at
strengthening or training of the individual muscle.
 The patient has to “re-learn” the movement patterns for functional activities
and maintenance of balance. The therapist teaches and guides the patient
to learn the movement patterns.
 The technique of the treatment is to treat the patient’s reactions and the
therapist is constantly guided by the responses of the patient to handling.
There is continuous feedback between the patient and the therapist as therapist
assesses during the treatment, the result of the technique utilized.
 The treatment techniques should be goal-oriented.
 The patient should always be treated as a whole. He is just not the arm,
hand or leg. He has his middle—the trunk.
 Aim always at body symmetry and midline.
 Perceptual deficits are trained mainly by guiding and not by commands.
The Fundamental Principle of Treatment

As CNS is constantly seeking input for output, Davies (1994) focuses her
treatment approach on the Input of the CNS emphasizing:
 Quality of touch.
 Minimization of fear.
 Removal of painful stimuli.

 Maintaining the dignity of the patient in every situation.
When damage occurs in one part of the brain, entire brain suffers from
the lack of communication.
Treatment Concept
In the treatment of the hemiplegia the progress, residual disability and adjustments
to affliction will depend on:
 Available resources in acute care.
 Severity of damage.
 Therapeutic approach.
Bobath’s and Davies’ concepts, from its very inception, are founded and
evolved on current neuro physiological, neurodevelopmental and
neuropsychological basis. The concept is based after considering the patient’s
movement problems, neuropsychological deficits and emotional status.
The entire concept is based on:
 Inhibition of spasticity and abnormal movement patterns.
 Facilitation of the movement patterns to near normal patterns of postures,
balance and performance of movement sequences without effort.
 Holistic approach, treating the patient as a whole and not just his arm
or leg.
As the problem is not the weakness of the muscles but that of the hypertonicity
and spasticity and abnormal movement patterns. According to the treatments,
principle of inhibition of spasticity and facilitation of near normal movements:
Normal movements cannot be superimposed on abnormal movement patterns
and tone.
The abnormal tone is suppressed throughout the body by incorporating RIPs,
at the key point of control in cardinal order. Proximally, these areas are head
and neck and trunk, shoulder and pelvic girdles and distally the wrist and
hand, ankle and foot, the weight bearing body parts. To estimate the potential
ability and to plan systematic treatment approach, qualitative motor and
somatosensory assessment is the basis for initial and follow up treatments.
The treatment from the day one is an ongoing process: That of teaching
and relearning. The therapist teaches and the patient relearns the different
patterns of posture, movements and balance. The nervous system learns by
performance and needs to get “in to the act”, so the patient has to be actively
involved in this activity and go through the process of learning to lay down
the memory engrams. Communication is mostly by tactokinesthetic channel
as the aim is to make the patient feel his environment (to be in touch with
it). He must perform maximally at his peak level to activate the reticular
system for attention and alertness.
In the early acute stage, respiratory care, correct positioning in semi prone
position on both sides and careful handling of the shoulder girdle and shoulder
joint helps to prevent setting in of strong hyper tonus and strong spastic patterns
of hemiplegic posturing and compensation from the sound side. Assist in avoiding
shoulder pain and shoulder problems.
The therapy program concentrates on:
 Head-neck orientation
 Activation of trunkal muscles, weight bearing and weight shifts.
 Through trunk activation of limbs movements, supporting the limb in RIPs
and working in small ranges without effort.
 Bilateral activities of the limbs to prepare the patient for midline awareness,
body symmetry and control and weight shifts in lying, sitting and standing.
As the spasticity reduces, the synergic element is broken down and the
patient is able to actively perform motor activity. Body tonus and movement
coordination are indivisible, they depend on each other. Retraining head neck
orientation with a freely mobile head with intact balance and equilibrium
reactions is very important for the patient to walk and move about without
the fear of fall. Fear means instability. Instability means lack of center of
gravity and base of support.
Where possible the patient must be taught to walk without support so that
his good arm is free for balance. Patients who show little recovery in arm
or leg can relearn the balance reactions remarkably well and recover ability
to take quick steps to regain their balance in standing and walking.
Constantly evaluate your treatment technique for feedback response. If the
desired response is lacking, analyze your handling (have you given too little
support, was the effort too much, was the patient held in good RIP) and
change your handling technique. Always start with the activity that the patient
can achieve and watch for the reactions throughout his body. Splinting provokes
exaggerated stretch reflex response, and hence, it is advocated to use the splinting
judiciously.
In case of hypotonia or flaccidity, tactokinesthetic stimulations are advocated
through:
 Inhibitory tapping
 Joint compressions
 Pressure tapping
 Brush and sweep tapping.
All these tapping procedures are to be cautiously applied to initiate motor

activity. The motor output will be in response to the sensory input. Following
restorative therapy, maintenance of the therapeutic care is very essential to
monitor any deterioration in movement quality.
Let us now consider one of the most used techniques of treatment, the
proprioceptive neuromuscular facilitation technique.
Proprioceptive Neuromuscular Facilitation (PNF)

Proprioceptive neuromuscular facilitation (PNF) is a philosophy and a method
of treatment. It was started by Dr Herman Kabat in the 1940s. Dr Kabat
and Margaret Knott continued to expand and develop the treatment techniques
and procedures. At first PNF was used as a treatment for patients with
poliomyelitis. With experience, it became clear that this treatment approach
was effective for patients with a wide range of diagnosis. Today PNF techniques
are widely used world over for the treatment of neurological and orthopedic
cases.
Definition
 Proprioception: having to do with any of the sensory receptors that give
information concerning movement and position of the body.
 Neuromuscular: involving the nerves and muscles.
 Facilitation: making easier.
PNF is a concept of treatment. Its underlying philosophy is that all human
beings, including those with disabilities, have untapped existing potential (Kabat
1950). PNF is an integrated approach. Each treatment is directed at a total
human being, not at a specific problem or body segment. The treatment approach
is always positive, reinforcing and using that, which the patient can do, on
a physical and psychological level. The primary goal of all treatment is to
help patients achieve their highest level of function.
Basic Neurophysiological Principles

The work of Sir Charles Sherrington was important in the development of
the procedures and techniques of PNF. The following useful definitions will
provide an exact insight on the neurophysiologic aspect of the technique.
 After discharge: The effect of a stimulus continues after the stimulus stops.
If the strength and the duration of the stimulus increase, the after discharge
increases also. The feeling of increased power that comes after a maintained
static contraction, is the result of after discharge.
 Temporal summation: A succession of weak stimuli (subliminal) occurring

within a certain period of time combined (summate) to cause excitation.
 Spatial summation: Weak stimuli applied simultaneously to different areas
of the body reinforce each other (summate) to cause excitation. Temporal
and spatial summation can combine for greater activity.
 Irradiation: This is a spreading and increased strength of a response. It
occurs when either the number of stimuli or the strength of the stimuli
is increased. The response may be either excitation or inhibition.
 Successive induction: An increased excitation of the agonist muscles follows
stimulation (contraction) of their antagonists. Techniques involving reversal
of antagonists make use of this property.
 Reciprocal innervation: Contraction of muscles is accompanied by
simultaneous inhibition of their antagonists. Reciprocal innervation is a
necessary part of coordinated movement. Relaxation techniques make use
of this property.
“The nervous system is continuous throughout its extent- there are no isolated
parts.”
Basic Procedures for Facilitation

The basic procedures for facilitation are:
 Resistance: To aid muscle contraction and motor control, to increase strength,
aid motor learning.
 Irradiation and reinforcement: Use of the spread of the response to
stimulation.
 Manual contact: To increase power and guide motion with grip and pressure.
 Body position and body mechanics: Guidance and control of motion or
stability.
 Verbal commands: Use of words and the appropriate vocal volume to
direct the patient.
 Vision: Use of vision to guide motion and increase force.
 Traction and approximation: The elongation or compression of the limbs
and trunk to facilitate motion and stability.
 Stretch: The use of muscle elongation and the stretch reflex to facilitate
contraction and decrease muscle fatigue.
 Timing: Promote normal timing and increase muscle contraction through
timing for emphasis.
 Patterns: Synergistic mass patterns, components of functional normal motion.
A combination of these basic procedures is done to get a maximal response
from the patient.
Techniques
The goal of the PNF techniques is to promote functional movement through
facilitation, inhibition, strengthening and relaxation of muscle groups. The
techniques use concentric, eccentric and static muscle contractions. These muscle
contractions with properly graded resistance and suitable facilitatory procedures
are combined and adjusted to fit the needs of each patient.
The techniques are,
 Rhythmic initiation
 Combination of isotonics
 Reversal of antagonists
– Dynamic reversal of antagonists and slow reversal
– Stabilizing reversal
– Rhythmic stabilization
 Repeated stretch or repeated contraction
– Repeated stretch from beginning of range
– Repeated stretch through range
 Contract-relax
 Hold-relax
 Replication
Rhythmic initiation: Rhythmic motions of the limb or body through the desired
range, starting with passive motion and progression to active resisted movement.
It aids in initiation of movement, improves coordination and sense of motion,
normalizes the rate of motion by either increasing or decreasing it, teaches
the motion and helps the patient relax.
Combination of isotonics: Combined concentric, eccentric and stabilizing
contractions of one group of muscles, i.e. agonists without relaxation. For
treatment, start with the range where the patient has the most strength or
best coordination. This technique activates control of motion, improves
coordination, increases the active range of motion, strengthens the muscles
and is effective in functional training in eccentric control of movement.
Reversal of antagonists: These techniques are based on Sherrington’s principle
of successive induction.
 Dynamic reversals: Active motion changing from one direction to the
opposite without pause or relaxation is the characteristic of this motion.
In normal life, we often see this kind of muscle activity, throwing a ball,
bicycling, walking etc. It helps in gaining active range of motion, increase
strength, develop coordination, i.e. smooth reversal of motion, prevent or
reduce fatigue and increase endurance.
 Stabilizing reversals: Alternating isotonic contractions opposed by enough

resistance to prevent motion. The command is a dynamic “push against
my hands or don’t let me push you”, and the therapist allows only a very
small movement. It increases stability and balance, increases muscle strength
and increases coordination between agonists and antagonists.
 Rhythmic stabilization: It is characterized by alternating isometric contraction
against resistance, no motion intended. It increases active and passive range
of motion, increases strength, increases stability and balance and decreases
pain.
Repeated stretch or repeated contractions:
 Repeated stretch from beginning of range: The stretch reflex elicited
from muscles under the tension of elongation is the main characteristic
of this technique. They facilitate initiation of motion, increase active range
of motion, increase strength, prevent or reduce fatigue and guide motion
in the direction desired.
 Repeated stretch through range: The stretch reflex elicited from muscles
under the tension of contractions is the rationale of this technique. It helps
to increase active range of motion, increase strength, prevent or reduce
fatigue and guide motion in desired direction.
Contract-relax:
 Contract-relax direct treatment: It is resisted isotonic contraction of the
restricting muscles i.e., antagonists, followed by relaxation and movement
into the increased range. It increases passive range of motion.
 Contract-relax indirect treatment: The technique uses contraction of the
agonistic muscles instead of the shortened muscles. “Don’t let me push
your arm down, keep pushing up.”
Hold-relax:
 Hold-relax direct treatment: Resisted isometric contraction of the
antagonistic muscles- shortened muscles, followed by relaxation. It increases
passive range of motion and decreases pain.
 Hold-relax indirect treatment: In the indirect treatment with hold-relax,
you resist the synergists of the shortened or painful muscles and not the
painful muscles or painful motion. If that still causes pain, resist the synergistic
muscles of the opposite pattern instead. It is indicated when the contraction
of the restricted muscles is too painful.
Replication:
This is a technique to facilitate motor learning of functional activities. Teaching
the patient, the outcome of a movement or activity is important for functional
work, e.g. sports and self-care activities. It is helpful in teaching the patient
the end position or outcome of the movement and assesses the patient’s ability
to sustain a contraction when the agonist muscles are shortened.
Goals of PNF Techniques

 Initiate motion
– Rhythmic initiation
– Repeated stretch from beginning of range.
 Learn a motion
– Combination of isotonics
– Replication
 Change rate of motion
– Dynamic reversals
 Increase range
– Stabilizing reversals
 Increase stability
 Increase coordination and control
– Replication
 Increase endurance
 Increase range of motion
– Contract-relax
– Hold-relax
 Relaxation
– Hold-relax
 Decrease pain
– Rhythmic stabilization or stabilizing reversals
– Hold-relax
After discussing the rationale of the Bobath and the PNF techniques, let
us now consider the Rood’s technique, which focuses on the facilitation of
neuromuscular system using various techniques.
The Rood Approach

The rood approach is based on the known physiological fact that the skeletomotor
units with different enzyme profiles play a distinct role in control of movement
and posture and how afferent input can influence different controls on these
in the central nervous system. The techniques are many times used for all
the neurological patients, majority being the hemiplegics. These techniques
are also used effectively in conditions like rheumatoid arthritis, osteoarthritis,
soft tissue injury and post-fractures. The techniques take the name after Margaret
Rood, an American Physical Therapist who in 1956, stated that ‘muscles have
different duties. Most of them are a combination, but some predominate, in
light work and others in heavy work (Tables 8.1 and 8.2). The essential features
of these techniques are:
 Identification of goals
 Identification of factors contributing to poor function
 Following a sequence of positions and activities of normal motor development
and selecting those most relevant to individual needs.
 Selection of appropriate afferent stimuli to exploit potentiality of tissues

to change at molecular level. This facilitates attainment of motor goals
and helps to prevent perpetuation of abnormal influences imposed by
pathological needs
 Pertinent timing of stimuli.
Ensuring repetition in association with environs, and thus, managed without
therapy, so that a lasting effect is obtained.
TABLE Muscle work patterns

8.1
Light work Heavy work
Phasic movement Tonic co-contraction
Fast glycolytic motor units Slow oxidative motor units
Superficial, usually multiarthrodial Deep one joint
Fusiform or strap, small area of Pinnate, large area of attachment
attachment
Great increase in blood supply if Rich blood supply at all times
active
High metabolic cost, rapidly fatigue Low metabolic cost, slow to fatigue
Flexors and adductors Extensors and abductors
TABLE Muscle work patterns

8.2
Light work patterns: Facilitated by Heavy work patterns: Facilitated by
Quick stretch Quick stretch
Unpleasant stimuli Joint compression in correct
alignment
Potentially harmful stimuli, Pressure on weight bearing
pain (nociceptors) surfaces, distal end fixed
Specific receptor sites on lips Resistance distally to extension
or abduction of proximal limb
joint
Input from semicircular canals, Input from utricle and saccule,
e.g. movement of head in space static position of head in space
Inhibited by: Inhibited by:
All stimuli for heavy work, e.g. All stimuli for light work, e.g. pain and
compression of long axis of the movement of head
body segments
Total movement is facilitated in the normal early patterns of curl up, stretch
out and rolling, omitting undesirable ones, e.g., total extension if extensor
spasticity predominates. This will secure any component, muscle activity or
movement, if necessary muscles are innervated and appropriate stimuli are
used. Postural stability is facilitated by using positions with the distal segment
fixed, and compression is given through correctly aligned head, trunk or limbs.
Movement, active or passive, over the fixed distal segments prepares for dynamic
stability. Lastly, movement is facilitated with the distal end of the part free.
Objective and functional activities are used. In all these, head control is obtained
before that of arms and upper trunk and lastly control of lower trunk and
legs, thus, the principle of cephalocaudal development is observed. Movement
control follows the sequence of flexion, extension, adduction, abduction and
lastly, rotation as in ontogenetic development (Table 8.3).
Receptors
Receptors are divided into six types depending upon the area where they
are found: cutaneous, muscle spindles, golgi tendon organs, mechanoreceptors
in dermis and joints, labyrinthine system and receptors in special sense organs.
 Cutaneous
– Cutaneous stimulation by quick light brushing: This is used as a
preparatory facilitation to increase excitability of motor neurons which
supply inhibited muscles. The area to be brushed is specific in terms
of the nerve root supply to skin and muscle; these must be the same
and the skin must lie on the same aspect of the part as does the muscle.
In most cases, the skin overlying the muscle shares its root supply. A
changing stimulus is needed and is continued only for a short time in
one place. A soft artist’s brush is used, or electronic brush may also
be used. For skin supplied by anterior primary rami, the excitatory effect
is local and mainly to superficial muscles, whereas, for the skin supplied
by the posterior primary rami, the effect is excitatory to deep muscles.
On the face, the effect is to the muscles of mastication and probably
to the muscles of expression through the intersegmental connections of
cranial nerves 5th and 7th. A delay of up to 20 minutes occurs before
the maximal effect if the nerve pathways to the inhibited muscles have
not been used recently. Rapid skin stimulation to the entire palm or
sole of feet will increase the blood circulation of the entire part.
– Brief application of the cold: In form of quick icing, this technique
is used for excitatory facilitation. This is most effective when the part
TABLE Sequences in gross motor development

8.3
A. Total Movement Descriptions Remarks
Patterns
A1 Supine Miss out in very young
Withdrawal pattern, except those with
total flexion, tonic posture extensor spasticity
pattern, heavy work, trunk,
neck and proximal
extremity joints.
Reciprocal innervations.
Bilateral. Centered at 10th
thoracic vertebra
A2 Roll over. Flexion top arm Use first for young child.
and leg. Phasic movement CVA
pattern Hemiplegics
A3 Pivot patterns. Avoid if extensor
Total extension. spasticity predominates
Reciprocal innervations.
Bilateral. Centered at 10th
vertebra
B. Fixed Distal
Segments
B1 Co-contraction neck, Use for hyperkinesias of
vertebral extension head and neck. Use to
stabilize eyes if nystagmus
B2 Forearm support.
Alignment must be
correct to avoid trauma
to glenohumeral joint
B3 All fours
B4 Sitting. Auto facilitation by
pressure on knees through
heels
C. Movements Examples: Rock side to
over fixed distal side, backward and forward,
segments to gain turning movements
mobile stability
D. Skilled movements Distal Objective activities, e.g. reaching,
end of limbs free crawling, walking
to be treated is warm and almost immediate effect is observed when

applied to the skin overlying the muscle.
– Slow stroking: If carried out from neck to sacrum, this can reduce choreo-
athetosis or excessive muscle tone. It should be applied rhythmically
for three minutes.
– Precautions:
• Use brushing for only three seconds in one place at one time, as,
a longer duration of application will inhibit rather than facilitate.
• In case of flaccidity, especially, in infant or young child with no
mechanism for response, brushing may cause a seizure.
• Avoid brushing to the external ears and outer thirds of forehead, as
this has a central inhibiting effect.
• Icing done behind the ear can reduce the blood pressure immediately.
• Ice applied to special receptor areas in the sole of foot or palm of
hand is potentially nociceptive so its usage should be avoided in very
young children and sensitive individuals.
• Ice can safely be applied over the lips and tongue as this is pleasant
but teeth can be avoided as it is painful.
• Ice applied over the skin supplied by the posterior primary rami may
set up a chain of effects on viscera over which one has no control.
• Ice used in the region of the left shoulder may be dangerous if there
is known cardiac disease.
 Muscle Spindles
– Quick unexpected stretch: On any muscle, this has a facilitatory effect
via the spindle afferents from a primary ending (1a) and must therefore
be avoided in spasticity.
– Slow full stretch: If this is applied to deep muscle components passing
over one joint only it will be inhibitory to the muscle stretched and
excitatory to the antagonists. Full length is gradually obtained and should
be held for five minutes. Other stimuli than follow to elicit correct postural
use of the part. The inhibitory effect is mediated via secondary spindle
endings (2). The therapist should avoid synergic muscles which are multi
jointed for the stretch as it would produce reflex inhibition in extensors
and excitation in flexors. A chain reaction can be gained—if slow stretch
is applied to soleus muscle, with the knee flexed, reciprocal activation
of dorsiflexion is obtained which in turn inhibits the gastrocnemius muscle;
the extensor thrust is prevented and a normal stance is facilitated. Other
groups of deep muscles which respond well are vastus medialis and
lateralis, the hip abductors, the lumbar and cervical deep extensors, the
posterior muscles of the glenohumeral joint and the shoulder girdle

retractors.
– Vibration: Muscle spindle can be stimulated by vibrations applied by
a mechanical device at the musculotendinous junction with the muscle
on stretch. The facilitation gained increases the strength of contraction
and may overcome inhibition in a muscle. This reflex is known as Tonic
vibratory reflex (TVR). Burke et al have shown that some fusimotor
drive to a muscle is essential for production of the TVR. Cutaneous
brushing prior to the use of vibrator should enhance its effect.
 Golgi Tendon Organs (1b)
– These receptors lie in series with contractile muscle fibers at the
musculotendinous junction and are also known as contraction receptors
and are auto inhibitory to a non-resisted repeated contraction of a muscle.
Their inhibitory effect can be cancelled by concurrent facilitatory
influences, so to exploit the inhibition no resistance is given even by
the force of gravity and a small range repeated contraction is requested.
– The patient is taught to produce repeatedly, very small range contraction
of the spastic muscle and its antagonist. There must be no resistance
even from gravity, the part should be supported, effort avoided and no
facilitation given. After many repetitions, stimuli can be given to elicit
strong isotonic contraction of the antagonistic extensor or abductor groups.
The spastic group of muscles is thus lengthened and the process can
be repeated using a starting position in which the spastic muscles are
longer than previously. Gradually, by several series of repetitions,
considerable relaxation can be gained.
– This technique is particularly useful for the adductors of hip and shoulder
joints.
 Mechanoreceptors in Dermis and Joints
– Receptors found in the ligaments and capsules of joints are known to
play a vital role in the control of posture and movement. A classification
of these receptors is given by Wyke (1972).
– Pressure on normal weight bearing areas increases activity in slow acting
motor units which are stabilizers of the posture. For example, pressure
under the medial side of the heel activates the dorsiflexor muscles which
evert the foot, facilitates dorsiflexion in eversion and corrects the tendency
to plantarflex and inversion in a spastic leg.
– If in the upper limb, the pressure is given to the heel of hand, spasticity
and protective muscle spasm are reduced and deep postural tone is
increased.
– Firm rubbing along the posterior border of the ulna and compression
through the long axis of the upper or whole arm, with the head of humerus
in its correct contact position with the scapula, will aid in decreasing
the spasticity. No pain should be elicited.
– When pressure from the top of the skull to the ischial tuberosities is
given through a correctly aligned and trunk, the deep postural muscles
are activated and the head and trunk stabilizes. A weighted cap or weight
cuff on shoulder can be used for this purpose.
– Prone positions, with the head or trunk unsupported, facilitate stability
by increase in postural tone.
– Pressure on the distal attachment of the superficial muscles and on the
palmar surfaces of the metacarpals allows the long flexor muscles to
be released.
 Labyrinthine System
– The position or movement of the head in space stimulates the receptors
in the utricle and saccule and in the semicircular canals. Static positions
will stimulate the utricle and saccule and influence postural tone; the
tonic labyrinthine reflexes of the neonate are modified as righting and
equilibrium reactions develop. The influence of retained or released tonic
reflexes must be observed and positions must be selected to reduce these.
– Movement of the head stimulates the semicircular canals and elicits
movement, reducing excessive postural tone and aiding the initiation
of movement in cases of bradykinesia. This is most effective with the
head in a vertical position and is easy to achieve by seating the patient
in a revolving chair.
– To elicit total extension of head, trunk and extension and abduction of
the limbs the patient is placed prone on a tilting plinth with the pivot
pattern.
 Receptors in Special Sense Organs
– Use should be made of stimulation of receptors in the nose and mouth
to mobilize the face or to elicit tongue movements. Examples include
using a drop of a dilute solution of quinine placed on the back of the
tongue to overcome tongue thrust and solutions of ammonia held under
the nose to release a Parkinsonian mask. Diluted unsweetened lemon
juice stimulates secretions from the throat.
– Optical righting reactions can be elicited and motivation is gained either
by looking at objects or following their movement. Rood techniques
have been used to facilitate the respiratory muscles in unconscious patients.
Timing
A selection of body positions and activities can be made so that the sequences
followed are timed for maximum facilitation. For example; skin brushing
precedes all other stimuli to allow for the delay in its facilitatory effect. Verbal
commands should coincide with the application of stimuli which gain an
immediate effect.
Repetition
Axoplasmic flow along nerve processes produces changes in the molecules of
nerve and muscle tissue. Repetition of regimes of activity over sufficient periods
of time is needed to effect changes in muscle unit so that they are more suited
to the demands made upon them. Regimes are planned for sufficient periods
regularly and over a long enough span to ensure lasting beneficial effects.
Treatment Planning
 Hypokinesia
– Skin brushing
– Total movement will facilitate any weak component
– Bone taps, quick ice, vibration
– Deep muscles—distal end of segments fixed, then applying compression
and resistance distally to gain co-contraction
– Rocking movements.
 Bradykinesia
– Semicircular canals—revolving chair, passive or active head and shoulder
rotation, alternate punching a suspended target
– Preparation for walking—use of poles held by patient and by therapist
from behind
– Auditory stimulation during each step.
 Hyperkinesia
– Ontogenetic sequences are used
– Stimulation of mechanoreceptors until deep muscles contract and hold
the position
– Weight bearing on prone is used.
 Spasticity
– Spasticity with some voluntary movement control:
a. Light brushing
b. Slow stretch
c. Non-resistant repeated contractions
d. Weight-bearing to facilitate mechanoreceptors. Compression pressure

on weight-bearing areas
e. To teach movement over fixed distal segments, finally eliciting selective
motor function
f. Specific position such as molding a hand around the cone.
 Released grasp reflex
Firm slow massage using the heel of the hand applied to the nonweight
bearing areas of the patients palm or the medial side of the sole of the
foot will inhibit grasp in an adult.
 Facilitation of swallowing and speech
– Light brushing to the upper lip, face and throat is used.
– Application of ice to lips and tongue gives facilitation.
– Resisted sucking is used as facilitation as well as it increases muscle
strength.
– Application of a wipe of ice to the lower neck anteriorly.
– Sucking or sipping a drink of diluted unsweetened lemon juice helps
to clear secretion in the throat by stimulating flow of thin saliva.
The following is an overview of a generalized protocol in the treatment
of hemiplegic patients.
Motor Control Training

General Considerations
Training should focus on improving motor control by stressing selective
movement patterns. Movement combinations that allow success in functional
tasks should be emphasized. Patients frequently respond to movement commands
with gross or mass patterns of movement and excessive effort. The linking
together of the proper components and the refinement of isolated control requires
a great deal of mental concentration and volitional control. Inhibition of unwanted
activity and excessive effort is crucial to the patient’s success. Movements
that are performed too quickly or too strongly will be ineffective in producing
the control needed. Initially, the therapist should select postures that assist
the desired motion and/or reduce tone and reflex interference. As control
develops, postures can be changed to more difficult ones that challenge
developing control. Resistance to movement should be minimal. Often the
resistance of gravity acting on the body, or slight manual resistance, is enough
to initiate or facilitate the correct muscular responses. Normal function implies
a tremendous variability in movement performance. Muscles need to be activated
in a variety of patterns and contexts. Eccentric contractions are generally easier
to perform than concentric. Isometric contractions are also important since
increased recruitment of static gamma motoneurons occurs, thus providing

additional facilitation for weak or hypotonic muscles. The clinician should
stress slow reciprocal movements. This emphasis on balanced interaction of
both agonists and antagonists is crucial for normal coordination and effective
function.
If the patient is hypotonic and/or unable to initiate movement, effective
strategies may include direct facilitation of movement using a variety of different
stimuli. Exteroceptive, proprioceptive and reflex stimulation techniques can
be utilized. Some disagreement exists, however, over the type of movements
that ought to be stimulated. Brunnstrom advocated the use of synergistic patterns
in early recovery for those patients unable to move at all. These patterns
are viewed as part of recovery and used to bridge the gap between flaccidity
and early movement. Once voluntary movement is achieved, synergistic patterns
are then modified to selective patterns. The use of synergistic patterns is therefore
limited to a small number of patients who demonstrate no voluntary return
of movement. Patients who have voluntary control would be inappropriate
candidates for this type of training.
Still others, adhering to the neurodevelopmental treatment (NDT) philosophy
developed by Bobath believed that emphasis on synergistic movements can
lead to an increase in spasticity, poor control of selective movement patterns
and widespread abnormal reflex activity. In NDT, the patient learns to control
tone and movement through the use of reflex inhibiting patterns that promote
“normal” selective movements during functional activities. Automatic reactions
are facilitated through the use of postural and sensory stimulation.
Coordination movement can also be promoted using PNF movement patterns.
For example, the therapist might select extension with the knee flexing if
the patient were experiencing incomplete knee flexion with hip extension at
toe-off. Appropriate PNF techniques might include slow reversals, timing for
emphasis with repeated contractions if components are deficient, or hold relax
active movement, if initiation of movement is difficult. The technique of agonistic
reversals is effective in developing the eccentric control necessary for normal
function. Thus, activities of bridging, stand to sit, or kneeling to heel-sitting
might be practiced.
Since patients with Hemiplegia present with variable symptoms, rigid
adherence to any one approach may yield unsatisfactory results. Most therapists
take an eclectic approach, selecting procedures from the different approaches
that have the greatest chance of success. Choice of therapeutic techniques
may also be dependent on other factors, including ease of delivering care,
cost-effectiveness and length of treatment. The success of a particular technique
also depends upon the physiotherapist who is delivering the therapeutic technique
and the response of the patient towards the same. There are multiple variables
in the patient care and hence, control of all is highly improbable. Thus, it
becomes next to impossible to actually quantify the research comparing any
two of the treatment approaches in the patients suffering from hemiplegia.
Tone Reduction
Patients who demonstrate the strong spasticity typically seen during the middle
phases of recovery may benefit from a number of techniques designed to
modify or reduce tone. These include positioning out of reflex-dependent
postures, reflex-inhibiting patterns that encourage movement of the weak and
hypotonic antagonists and avoiding excess effort and heavy resistance. Rhythmic
rotation of limbs with slow, steady passive movement out of the spastic pattern
may also serve to decrease tone, while providing ROM to the spastic limb.
A reduction in truncal tone can be promoted through techniques of rhythmic
initiation or slow reversals combined with upper and lower trunk rotation.
Postures of sidelying, sitting, or hook lying are frequently used. Proprioceptive
neuromuscular facilitation extremity or trunk patterns (chopping or lifting)
that emphasize diagonal and rotational movements combined with techniques
designed to reduce tone (e.g. rhythmic initiation) may also be helpful. Local
facilitation techniques may prove successful in stimulating weak antagonists
and reducing spasticity in some patients. However, as Bobath points out,
reciprocal relationships are not always normal, particularly in the presence
of strong spasticity, so that these techniques may be ineffective, serving to
increase rather than decrease tone in the spastic muscles. Exercise procedures
that take advantage of prolonged pressure on long tendons and the resultant
inhibition are also effective in reducing tone. A common exercise for hemiplegics
involves weight bearing on an extended, abducted and externally rotated arm
with the wrist and finger extended. Slow rocking movements add to the inhibitory
effect on the spastic wrist and finger flexors. Spasticity in the quadriceps
can be similarly inhibited through weight bearing in kneeling or quadruped
positions. Orally inflatable pressure splints have also been used effectively,
to assist in the maintenance of inhibiting patterns by providing prolonged
stretch and inhibition to spastic muscles. They also aid in providing stability
and allow early weight bearing on a limb during training activities.
Techniques that promote a generalized reduction in tone by decreasing CNS
arousal mechanisms, include slow stroking down the posterior primary rami,
and soothing verbal commands. Gentle rocking works through the vestibular
system to also produce a generalized reduction in tone.
FIGURE 8.1: Quick ice dipping for activating finger extension, left hemiplegia
FIGURE 8.2: Active finger extension after icing, left hemiplegia
Myofascial release techniques, better known as MFR, can reduce the tone
of the spastic muscles, significantly. During the process itself, when the therapist’s
fingers are moving on the patient’s spastic muscles, relaxation of the muscles
and soft feel of the relaxed muscles can be perceived. All the other techniques
of treatment usually follow MFR and prolonged icing in a spastic case (Figure
8.1). The ease of the other exercises increases with this method.
Prolonged icing using ice wraps, ice packs, or ice massage may decrease
spasticity by slowing conduction in nerves and muscles and decreasing muscle
spindle activity (Figure 8.2). Once tone is reduced, the therapist should emphasize
active movement out of the positions of spasticity. This can prolong the inhibitory
effects and produce restrictive movements.
Compensation for Sensation Loss

Patients who have significant sensory loss may demonstrate impaired or absent
spontaneous movement because of the lack of feedback signals before and
during movement. The more the patient can be made to use the affected side,
the greater the chance of increased sensory awareness and function. Conversely,
the patient who refuses to use the hemiplegic side contributes to the problem
of persistent lack of sensorimotor experience. Without attention during treatment,
this ‘learned nonuse’ phenomenon can contribute to further deterioration.
Treatment should, therefore, involve the patient using the hemiplegic side in
volitional motor tasks.
The presentation of repeated sensory stimuli will maximize use of residual
sensory function and CNS reorganization. Stretch, stroking, superficial and
deep pressure and weight bearing with approximation can all be used during
therapy to increase sensory input (Figure 8.3). Training should also focus
on localization of touch. Electrical stimulation has been used to assist in activation
and localization of sensorimotor responses. The selection of inputs should
be directly related to the functional task at hand and provided to those surfaces
directly used in the task (Figure 8.4). Stimulation should be of sufficient intensity
to engage the system but not to produce adverse effects (Figure 8.5).
FIGURE 8.3: Sensory stimulation using deep pressure by texture ball, left
hemiplegia
FIGURE 8.4: Various articles used for sensory stimulation and stereognosis
FIGURE 8.5: Self sensory activation by using palmar surface on face, left hemiplegia
Johnstone suggests that inflatable pressure splints can be used during treatment
to provide additional sensory stimulation to deep pressure, muscle and joint
senses. In more severe cases, she suggests a program of intermittent pressure
therapy to stimulate movement within the tissues and overcome problems of
sensory accommodation.
A safety education program for awareness of sensory deficits and care of
anesthetic limbs should also be instituted. This is particularly important for
preventing upper limb trauma during transfer and wheelchair activities. Training
for those patients with hemianopsia and unilateral neglect traditionally includes
emphasis on scanning the visual environment on the affected side.
Motor Learning Strategies

Recovery from hemiplegia is based on the brain’s capacity for reorganization
and adaptation. An effective rehabilitation plan capitalizes on this potential
and encourages movement patterns closely linked to normal performance.
Function should be stressed at all times and the function should be meaningful
and important to the patient. Optimal motor learning can be ensured through
attention to a number of factors. Demonstrate the desired task at the ideal
performance speed. Manually, guide the patient through the desired movement
to assist in his or her understanding of the task and its components. Encourage
early active participation of the affected side. Practicing the movements on
the unaffected side first (Figures 8.6 to 8.8) can yield important transfer effects
to the affected side.
FIGURE 8.6: Bilateral upper limb usage, note the use of subluxation strap, Bobath
type, left hemiplegia
FIGURE 8.7: Bilateral upper limb usage using a dynamic object like a ball, left
hemiplegia
FIGURE 8.8: Weight-bearing in parallel bar
Simultaneous practice of similar movements on both sides can also improve

learning, while promoting integration of both sides of the body. Visualization
of the movement components can help some patients in initially organizing
the movement. During early learning visual guidance is extremely important.
This can be facilitated by having the patient watch the movement. If the patient
needs glasses, make sure they are worn during therapy. Use of mirror can
be an effective technique for some patients to improve visual feedback, especially
during postural activities.
During later learning, proprioception becomes important for movement
refinement. This can be encouraged by early and carefully reinforced weight
bearing on the affected side in upright activities. Additional proprioceptive
inputs (manual contacts, tapping, stretch, tracking resistance, antigravity postures,
or vibration) can be used to improve movement feedback and stimulate the
necessary components. The patient should be encouraged to “feel the movement”
and learn to recognize correct movement responses from incorrect ones. Assist
the patient in learning to eliminate the unnecessary movement components.
Exteroceptive inputs (light rubbing, brushing, and ice application) may provide
additional sources of information, particularly where distortions of proprioception
exist. However, great care must be taken to avoid sensory bombardment or
feedback dependence. To do this, requires careful assessment during each

treatment session. Pain and fatigue (either mental or physical) should be avoided,
since each will be associated with a decrease in motor performance. Careful
attention to the learning environment will also yield important therapeutic
gains. Reduce distractions and provide a consistent and comfortable place
in which the patient can exercise. Provide clear, simple verbal instructions;
do not overload the patient with excessive or wordy commands. Monitor
performance carefully and give accurate feedback. Reinforce correct performance
and intervene when movement errors become consistent. Organize the patient’s
schedule so that practice sessions are relatively short and the patient has adequate
rest. Coordinate staff efforts to ensure that the patient is being asked to perform
the task consistently with the same performance expectations. Progress and
challenge the patient with a new task as soon as the previous one has been
mastered. Encourage the patient to be self-sufficient and to develop self-
assessment skills, goals, and problem-solving skills. Begin and end treatment
sessions on a positive note, ensuring the patient has success in treatment and
continuing motivation. Finally, communicate, support, and encourage the patient;
recovery from stroke is an externally stressful experience and will challenge
the abilities of both patient and therapist.
Treatment Program in Acute Stage 139
C H A P T E R
9
Treatment Program in
Acute Stage
INTRODUCTION
The entire treatment program given in the following sections is integrated
and designed so that all the important aspects of effective techniques are
incorporated. The practicing therapist can modify the program as per the
requirement of the patient.
Initially, when the patient is diagnosed with hemiplegia due to any of the
causes, the effect on the patient as well as the close relatives is that of a
catastrophe. The word ‘paralysis’ itself has a huge weight attached to it. Thus,
in the initial stages, it is important that the primary caretakers as well as
all the members of the rehabilitation team educate the near and dear ones
of the patient regarding the realistic prognosis. Many a times, it is not possible
to give an exact picture of the prognosis, but nevertheless, the negative effect
of the word ‘paralysis’ should be counteracted by the positive approach.
Physiotherapy for the hemiplegic patient can be grossly divided into 5 stages
which are as follows:
1. Neurointensive care unit (NICU).
2. Transient care unit (TCU).
3. Wards.
4. At patient’s residence.
5. Outpatient-based department of the physiotherapy clinic.
Let us discuss the mode of physiotherapy treatment in all these stages.
DURING NICU AND TCU STAY

Initial stages of the treatment at the intensive care units are of utmost importance
in saving the valuable life of the patient. From first few hours to a few days
FIGURE 9.1: Patient in NICU
are very critical for the patient as well as the caretakers. For a physiotherapist,
apart from being prompt and technically correct in therapy, being polite, caring,
dedicated and remaining positive and using a positive and affirmative language
will make wonders for the patient, as well as, for the near and dear ones.
Usually, the patient may have a number of lines like: the Ryle’s tube for
feeding, parenteral line for fluid balance and medicines, endotracheal tube,
indwelling urinary catheter or external catheter, etc. (Figure 9.1). Managing
physiotherapy with these lines will be a challenge. Virtue of patience will
pay off during this time.
Rehabilitation during the acute stage can begin as soon as the patient is
medically stabilized, typically within 72 hours. Goals of physical therapy during
the early rehabilitation will include:
 Maintain ROM (range of motion) and prevent deformity
 Promote awareness, active movement and use of the hemiplegic side
 Improve trunk control, symmetry and balance
 Improve functional mobility
 Initiate self-care activities
 Improve respiratory and oromotor function
 Prevent secondary complications
 Monitor changes associated with recovery
 Minimize the feeling of fear of ‘paralysis’ for the patients and immediate
relatives.
Treatment must commence immediately after the onset of hemiplegia. Progress
will be more rapid if the patient is treated two or three times a day in the
early stages, even if only 10 minutes at a time. The patient’s ability and tolerance
are directly related to the site and severity of the lesion and his physical
condition prior to the illness rather than to the length of time since the incident.
Treatment must progress accordingly. Most patients are able to sit out of bed
within a few days and it is important for them to move from the ward or
bedroom so that they are stimulated by the changes of surroundings. Shaving,
wearing make-up and dressing in everyday clothes, all help to overcome the
feeling of being an invalid.
Rehabilitation in a hospital department has the advantage of invaluable
contact with other people and patients with similar problems as well as the
stimulation of leaving home and dealing interdependently with new situations.
Adequately instructed relatives and friends can provide a very effective learning
environment and are often able to give more reinforcement to the concept
of rehabilitation.
PULMONARY OR CHEST PHYSIOTHERAPY

In the initial stages, if the patient is unconscious, pulmonary physiotherapy
inform of airway clearance and minimizing and treating lung complications
isvital. Following methods are usually employed for the same.
 Segmental Breathing Exercises: The segmental breathing exercises are
carried out by placing the hands on the chest wall of the corresponding
part of the lung i.e., apical, middle and basal. Basal lobes are more likely
to be involved during the long term stay in bed. Just by placing the hands
on the part, expansion can be maintained as the air fills up that part of
the lungs. Adding gentle pressure will provide sensory input to the part
which is being treated. At the end of expiratory phase, gentle overpressure
can be given to aid in increased inspiratory phase in the next breathing
cycle.
 Abdominal Breathing and Activation of Diaphragm: Place the hands
on the diaphragm and the lower costal margins. Gentle overpressure will
aid in abdominal breathing. A palm placed directly over the upper abdominal
region with gentle overpressure will also aid in abdominal breathing. For
a right handed therapist, the right elbow flexed can be placed on the right
side of the iliac crest and the forearm should cross the abdomen and the
palm should rest on the left lower costal margin. With the thumb of the
extended right palm resting on and palpating the diaphragm, gentle breathing
by the patient is allowed to continue. This technique is beneficial for the
patients who do not possess adequate strength of the diaphragm.
 Vibrations and Percussions:Vibrations given during the expiration phase
will allow secretions to mobilize and get collected near principle bronchus
from where, they can be suctioned out. Vigorous percussions like shaking
and clapping can be avoided in the initial stages but can be used judiciously.
However, in case of complications like pneumonitis (which is fairly common),
or lung consolidation and collapse, vigorous chest Physiotherapy three to
four times a day and two to three times in the night time is strongly indicated.
 Suction: Nebulizers are used prior to and after the treatment to expand
the airways and aid in draining out the secretions. Suction is always done
immediately after the therapy and again after a time period of about 15
minutes. This suction which we are talking about is in addition to the suction
which is regularly carried out by the nursing staff round the clock. Suction
catheter should be kept in the cavity for not more than 3 seconds at a
time, as more time will create negative pressure within the airways of lungs.
This procedure can be repeated as many times as required, till majority
of the secretions are drained. The suction catheter should be introduced
very slowly and gently with circular motion around its axis to avoid any
injury inside the pharynx, the larynx or the bronchus. If by oral suction
the secretions are not properly drained, an oral airway can be used to avoid
the biting of the suction catheter. Many a times, a nasal airway has to
be used to clear out the pharyngeal secretions. A laryngoscope has to be
used to reach deeper into the larynx for more effective suction. During
suctioning, a fall in the saturation of patient’s oxygen level or fluctuations
in heart rate are taken care of and any change if seen, suctioning is immediately
discontinued till the patient stabilizes. It should be a matter of common
sense to take all the necessary aseptic precaution while dealing with the
patient in ICU or elsewhere. It is beneficial for both the patient as well
as the therapist. Physiotherapy for the patient on artificial respirator or
ventilator should be referred to additional reading recommended as it is
a specialized subject in itself.
 For chest physiotherapy, a compromise on the patient’s positioning can
be made as it may not be possible to give a head low position to majority
of the patients with hemiplegia due to brain dysfunctions. Also, due to
various lines and drains, it may be difficult to maintain side lying position
and hence, whatever available position is used to deal with the lungs. Head
up position of 30 to 40 degrees is strongly recommended, as this position
avoids falling back of tongue which may be a cause of asphyxia. This
position will drain the apical lobes automatically. The pressure of the
abdominal organs on the lungs will be avoided by this position.
 Proprioceptive neuromuscular facilitation (PNF): Proprioceptive patterns
can be used to increase the chest expansion. Intercostal stretch is a useful
tool to gain chest expansion. Mobilization of thorax in side lying will ensure
maintenance of thoracic cage mobility. Overpressures to entire thoracic cage

during expiration will facilitate draining of secretions as well as inspiration.
Mild resistance to inspiration will facilitate it furthermore.
If the patient during the ICU stay is conscious and obeying verbal commands,
the therapy program can be:
 Deep breathing exercises with pursed lips
 Deep breathing exercises with elongated expiratory phase
 Segmental breathing exercises
 Segmental breathing exercises with gentle vibrations
 PNF
 Active positioning
 Huffing and coughing
 Inspiratory incentive spirometry with calibrations for records of the daily
progress of vital capacity
 Balloon spirometry for expiration and fun
 Chest expansion active and assisted
 Abdominal breathing exercises.
Usually a program of 5 to 10 deep breaths per hour is excellent workout.
Over the day, a program of spirometry can be done many a times. Remaining
therapies can be coordinated at every 2 to 3 hours. Making the patient sit
up in the bed as soon as possible, will enable the chest to remain healthy.
All the therapies may be discussed with the consultant of the patient for smooth
functioning.
POSITIONING
Within the first few days, the physiotherapist should meet the patient’s relatives
and explain patient’s difficulties and how they can help to overcome them.
They will appreciate being involved and having something concrete to do
while visiting; they often have more time to spend with the patient than either
tend to sit on his unaffected side as his head is usually looking that way
and, it is easier to gain his attention. They should sit on his affected side
and be shown how to turn his head towards them by placing a hand over
his cheek and applying a firm prolonged pressure until the head stay round.
They should then strive to attract his attention by encouraging him to look
at them and talk to them. Their conversation presence will stimulate him and
help to restore his state of awareness. Holding his affected hand will give
sensory stimulation and bring awareness of the limb. Initially, interested relatives
can encourage the patient to do his self-assisted arm exercises and later, they
can encourage other appropriate activities such as correcting posture and assisting
in the therapeutic performance of self-care activities.
Instruction for Nurses and Relatives

Careful instructions and involvement of nurses and relatives are of paramount
importance and will eliminate or minimize many of the complications associated
with hemiplegia.
Position of the Bed in the Ward

The patient benefits if the position of his bed in the ward or room makes
him look across his affected side at general activity or items on his affected
side; he has to reach across the midline for a glass of water, napkin, etc.
Nursing Procedures
Great therapeutic value can be incorporated in routine procedures by encouraging
the patient’s participation. While bathing him in bed, the nurse can focus
his attention on each part of the body by naming it and, asking for his help
to facilitate washing, e.g. rolling on to his side with her and holding up the
affected arm with the sound hand; or rolling actively as she is making the
bed. When a bedpan, medicine or food is brought to the patient, the approach
should be from his affected side, thereby increasing his awareness of it.
Position the Patient in Bed

The bed must have a firm mattress on a solid base and the height should
be adjustable. It will need to be lowered to enable easy and correct transfer
of the patient into a chair. Five or six pillows will be required to maintain
the correct alignment of the head, trunk and limbs. The patient’s position
should be changed frequently. Two to three-hourly turning is advisable in
the early stages while the patient is confined to bed. Even when he is out
of bed during the day and more active, correct positioning at night must continue.
Position Lying on the Affected Side

• The head is forward with the trunk straight and in line
• The underneath shoulder is protracted with the forearm supinated
• The underneath leg is extended at the hip and slightly flexed at the knee
• The upper leg is in front, on one pillow
• Nothing should be placed in the hand or under the sole of the foot because
this would stimulate undesirable reflex activity, i.e. flexion in the hand
and extensor thrust in the leg.
Position Lying on the Sound Side

• Patient is in full side lying, not just a quarter turn.
• The head is forward with the trunk straight and in line. If necessary, a
pillow under the waist will elongate the affected side further.
• The affected shoulder is protracted with the arm forward on a pillow.
• The upper leg is in front, on one pillow. (The foot must be fully-supported
by the pillow and not hang over the end in inversion).
• A pillow is behind the back.
• Nothing should be placed in the hand or under the sole of the foot.
Position in Supine
• The head is rotated towards the affected side and flexed to the good side.
• The trunk is elongated on the affected side.
• The affected shoulder is protracted on a pillow with the arm elevated or
straight by the side.
• A pillow is place under the hip to prevent retraction of the pelvis and
lateral rotation of the leg.
• Nothing should be placed in the hand or under the sole of the foot.
In the supine position, there will be the greatest increase in abnormal tone
because of the influence of reflex activity, and this position should be avoided
whenever possible.
Positioning of the patient is one of the first considerations during early
rehabilitation. The room should be arranged to maximize patient awareness
of the hemiplegic side. A bed positioned with the hemiplegic side towards
the main part of room, door and source of interaction will stimulate the patient
to turn toward and engage the affected side. The resulting sensory stimulation
to the stroke side promotes integration and symmetry of the two sides of
the body. However, this may be contraindicated in cases of unilateral neglect
or anosognosia, since the arrangement may contribute to sensory deprivation
and withdrawal.
Early on, the patient is likely to spend significant time in bed and effective
positioning program seeks to prevent undesirable postures, which can lead
to contractures or decubitus ulcers. Since, most stroke patients will become
spastic, a positioning program also aims to position the patient out of tone-
dependent and reflex-dependent postures. Patients are generally placed on a
positioning schedule, with turning every 2 to 3 hours. Assumption of upright
postures is promoted as soon as possible.
The following postures should be ‘totally avoided’:

• Lateral side flexion of the head and trunk toward the affected side with
head rotation toward the unaffected side.
• Depression and retraction of the scapula, internal rotation and adduction
of the arm, elbow flexion and forearm pronation, wrist and finger flexion.
• Retraction and elevation of the hip, with hip and knee extension and hip
adduction; or hip and knee flexion with hip abduction. Ankle plantar flexion
is common to both.
The supine position should be balanced with other positions since there
is a high risk of pressure sore development in the sacral area, heel and lateral
malleolus, if the leg is externally rotated. It also maximizes reflex effects.
Thus, extensor tone associated with the tonic labyrinth reflex and tonal responses
associated with head positions of the tonic neck reflexes may be promoted.
A footboard should be avoided since abnormal extensor responses of the foot
and leg may be stimulated with a contact stimulus to the ball of the foot.
Similarly, objects should not be placed in the hand, since the grasp reflex
may be stimulated, increasing flexor spasticity. Attention should also be directed
to the hemiplegic shoulder. Correct positioning protects the shoulder from
downward displacement by controlling the scapula position in slight protraction
and upward rotation. Gentle approximation forces through the shoulder joint
can also assist in preventing shoulder subluxation.
Due to presence of various indwelling lines for the intravenous fluids, Ryle’s
tube, indwelling catheter, nasal or oxygen with mask and/or endotracheal tube,
it is difficult for the nurses and the therapist to give a proper positioning
to the patient. Care should be taken so as to avoid the disturbance to the
lines which are life-saving. Nevertheless, the importance of the proper positioning
should not be compromised at any cost. Initially, the Medical staffs as well
as the patient’s relatives are anxious about the lifesaving measures for the
patient. Thus, it is the duty of the therapist to make sure about the avoidance
of the faulty postures and promotion of good positioning.
Common positions that should be promoted include:
 Lying in the supine position: As explained above, the head and trunk
should be positioned in midline or flexed slightly toward the sound side
to elongate muscles on the hemiplegic side. A small pillow or towel under
the scapula wall assists in scapula protraction. The arm can rest on a supporting
pillow, extended and in abduction, with wrist and finger extension. The
pelvis is protracted with the leg in a neutral position relative to rotation.
The affected knee is positioned with a small towel roll to prevent
hyperextension.
 Lying on the sound side: When the patient is lying on the unaffected
side, the trunk should be straight. A small pillow under the cage can be
used to elongate the hemiplegic side. The affected shoulder is protracted
with the elbow extended and the forearm is neutral or supinated. The pelvis
is protracted and the affected leg flexed at the knee with hip extended,
in neutral rotation and supported by a pillow (Figures 9.2 and 9.3).
FIGURE 9.2: Lying on the sound side, right hemiplegia
FIGURE 9.3: Lying on unaffected side with pillow support, right hemiplegia
 Lying on affected side: When the patient is lying on the affected side,
the trunk should be straight. The affected shoulder underneath is positioned
well forward with the elbow extended and forearm supinated. The affected
leg is positioned in hip extension with knee flexion. An alternate position
has slight hip and knee flexion with pelvic protraction. The unaffected leg
is positioned in flexion on a supporting pillow.
 Sitting: The patient should sit upright with trunk and head in midline
alignment. Symmetrical weight bearing on both buttocks should be
encouraged. The legs should be in neutral with respect to rotation. When
sitting in bed, pillows may be needed to bring the trunk to the upright
position. When sitting in a chair, the hips and knees should be positioned
in 90 degrees of flexion, with weight bearing on the posterior thighs and
with the feet flat. In bed, the arm can be supported on a pillow or adjustable
table, while in a wheelchair, an arm board or lap board can be used. The
scapula should again be slightly protracted with wrist and fingers extended
in a functional open position.
PASSIVE RANGE OF MOTION EXERCISES

Passive ranges of motion exercises are most vital during initial stage. They
create an imprint on the brain, aid in peripheral blood circulation, prevent
tightness, contractures and deformities, and prevent bedsores and deep venous
thrombosis (DVT). Passive movements can be carried out in full range of
motion wherever applicable, 10 to 15 repetitions for each joint, 4 to 5 times
a day. Therapist can start from periphery (fingers and toes) to head or from
head to periphery. Usually, head righting and trunk righting is recommended,
prior to any limb mobilization for increased effectiveness. Positioning for head
and trunk, as discussed earlier is important for a sequential rehabilitation.
For a patient who is unable to maintain the position, frequent change in position
has to be organized by the caretakers. For ease in application, a sequence
is described below:
 Head and neck: Flexion, extension, side flexion to right, side flexion to
left, rotation to right and rotation to left.
 Trunk: Upper trunk rotation to right and left, lower trunk rotation to right
and left, assisted pelvic tilts, flexion of trunk, extension using pillows in
supine-lying, or another easier method is stretching in side-lying position,
side stretches on both the sides when the patient is in side-lying position.
One hand can be kept on the anterior-superior iliac spine and other hand
crosses and is held beneath the scapula at its inferior angle. Stretch is
applied by taking the two points apart.
 Scapulae: All the mobilization of scapula is done along the thoracic cage
only. If viewed from sides, the thoracic cage is convex from top to bottom
and from side to side, hence, the scapula moves in the similar fashion
on the thoracic cage. Scapular mobilization, passively, can be carried out
either in supine or side-lying. Side-lying position is a better position as
moving scapula can be viewed easily. Care should be taken as to not suspend
the flail hemiplegic limb to protect the glenohumeral joint, which is suspended
only by the muscular support.
Sequence of the movements may be: Elevation, depression, protraction,
retraction, upward rotation, downward rotation, and combination of these
movements. Tipping of scapula is avoided due to chances of injury to the
rotator cuff musculature.
 Shoulder (glenohumeral) joint: The entire upper extremity should be well

supported while performing movements. One hand of the therapist holds
the palm with abducted thumb and other hand is kept at the elbow joint
to stabilize it. The sequence of the movement can be: Flexion, extension,
abduction, adduction, internal rotation, external rotation in full range of
motion. Passive movements can be also performed in a PNF pattern, e.g.
scapula: Elevation, retraction; shoulder: Flexion, abduction, external rotation;
elbow: Extension; radioulnar: Supination; wrist: Extension, radial deviation;
fingers: Extended and abducted; thumb: Extended and abducted.
 Elbow joint: Flexion and extension is carried out in a gentle manner. Risk
of myositis ossificans is kept in mind.
 Radioulnar joint: Pronation and Supination. In this mobilization, grip is
of importance. One hand is kept on the elbow at the cubital fossa and
other hand grips the lower end of radius and ulna, just before the wrist
joint and the pivot force is applied. The therapist’s hand should not cross
the wrist joint while mobilization because, if done so, a shearing force
(twisting) is diverted towards the wrist joint, in case of a stiff radioulnar
joint which will produce pain in the wrist.
 Wrist joint: Flexion, extension, radial deviation, ulnar deviation.
 Fingers: Flexion, extension at metacarpophalangeal (MCP), distal
interphalangeal (DIP), and proximal interphalangeal (PIP) joints individually
as well as together for all fingers, abduction (fanning) and adduction of
fingers, intermetacarpal glides.
 Thumb: Flexion and extension at carpometacarpal (CMC) and interphalangeal
(IP) joints, abduction, adduction, opponens and circumduction.
 Hip joint: Flexion, extension (up to neutral in supine, can be extended
further in side-lying), abduction, adduction, external rotation, internal rotation.
 Knee joint: Flexion, extension. Proper care is taken while carrying our
passive or assisted knee mobilization. One palm of the therapist is kept
beneath the knee joint on the popliteal fossa to prevent the knee from
snapping during extension. As during the initial stages, the muscles are
flail, ligaments of the knee may get damaged due to improper handling.
 Ankle and subtalar joints: Dorsiflexion, plantar flexion, inversion and
eversion.
 Foot and toes: Intermetatarsal glides, toes flexion and extension.
All the above mentioned movements are carried out gently without much
application of force. The speed of movement is kept slow and rhythmic. Undue
stimulation of sensitive structures is avoided, e.g. sole of feet, ball of great
toe, palmer area, as it may produce exaggerated response due to sensory loading.
These movements can be carried out in the sets of 10 to 15 repetitions, 4

to 5 times in a day or as the need be.
If the patient has regained lost consciousness and is in a position to obey
verbal commands, assessment of the volitional activities is carried out and
accordingly, active exercise treatment protocol is designed and planned. General
contraindications of movements and mobilizations are kept in mind. Jerky
movements and gross movement patterns using momentum are not allowed
as it leads to development of abnormal reflex pattern activity. E.g., clenching
fists prior to the development of wrist and fingers extensors will inhibit opening
of fingers. Straight leg raisings will promote extensor thrust in lower limbs
which is decremental for patient’s gait.
RANGE OF MOTION AND PREVENTION OF

LIMB TRAUMA
Range of motion exercises during early recovery maintains normal range in
flaccid, non-functional limbs and maintains mobility of the joint capsule. In
the upper extremity, correct ROM techniques should include careful attention
to external rotation of the arm with scapular mobilization and upward rotation
during shoulder elevation activities (Figures 9.4 and 9.5). If the motions are
not performed, the patient is likely to experience shoulder impingement, rotator
cuff injury and pain. The use of overhead pulleys for self-ROM is generally
contraindicated for the above reasons. Full ROM should be performed in all
shoulder motions. Inadequate ranging can lead to the development of adhesive
capsulitis and/or shoulder hand syndrome. Tightness and swelling of the wrist
and finger flexors may develop. Daily range of motion, elevation, massage,
icing, or compression wrapping may improve the status of the hand. Splinting
in a functional position can also be considered. Either dorsal or volar resting
pan splints that incorporate the forearm, wrist, and hand are commonly used.
During position changes, care must be taken not to pull onto the arm or let
it hang unsupported, since the risk of traction injury would be increased. A hemi
sling with pads beneath the elbow and wrist and/or hand may be used to support
the arm and prevent subluxation. While such slings are effective in mechanically
supporting the shoulder during activity, they have the negative feature of
positioning the arm close to the body in adduction and internal rotation. With
prolonged use, contracture and increased flexor tone may develop. Slings may
also impair trunk mobility, balance reactions, and positive body image. An alternate
approach to the tradition sling is a humeral cuff maintained by a figure-eight
harness (Bobath sling). This device supports the upper arm and shoulder with
a cuff while avoiding the internal rotated, flexed arm. Careful monitoring of
FIGURE 9.4: Range of motion exercise, left hemiplegia
FIGURE 9.5: Range of motion exercise for lower extremity, left hemiplegia
circulation is necessary when using this type of sling. A padded arm through
attached to the arm of a wheel chair is a third type of device commonly used.
The support height and arm position are adjusted to control subluxation. In a
study comparing the effectiveness of three different devices, the hemi sling and
arm though proved more effective than the Bobath sling in controlling subluxation.
As spasticity emerges, the use of a sling is generally contraindicated. Care
must be taken to mobilize the arm and prevent prolonged posturing, especially
in internal rotation and adduction with pronation, wrist and finger flexion.
Full range of motion in shoulder elevation activities (stressing elongation of
the pectoralis major and latissimus dorsi with scapular rotation) should be
maintained. Exercise procedures should concentrate on the action of the serratus

anterior, emphasizing scapula upward rotation. This can be accomplished in
a number of postures (supine, side-lying, or sitting) using the techniques of
placing and holding, or modified hold-relax active movement with the arm
externally rotated and extended, and an open hand.
START WITH THE MIDLINE

As soon as the patient is able to comprehend the instructions given, midline
orientation in a more active form is started. All the reactions are practiced in
midline so as to improve the memory of normal truncal movement in the brain.
After the head and neck righting as described earlier, abdominal activation is
started. It can be done by various methods. Initial protocol is described below.
 In supine-lying, gradual stroking is done on the abdominal muscles in an
oval route with three fingers (index, middle and ring) of the therapist by
applying gentle pressure. Both the sides are stroked starting from end of
the sternum to the area below the umbilicus in the line of anterosuperior
iliac spines. This is done in an oval route covering also the obliques. In
the Figures 9.6 and 9.7, rib cage elevation is seen which is due to insufficient
abdominal muscles.
 If during the respiration, lower rib cage is elevated as seen in the Figure
9.7, then, during the activation of abdominals, gentle compression of the
rib cage is carried out for facilitation of the muscles.
 Head raises will contract the abdominals as they act as stabilizers.
 Bridging which is a common exercise with all therapists is not practiced
unless the abdominal activation is present.
 Turning to both the sides with total flexion pattern is taught to the patient.
Many goals and treatment activities, begun during early recovery, are
continued throughout the course of the patient’s rehabilitation. Some are modified
to appropriately challenge the patient and propel him or her to optimal recovery.
During the middle and late stages of recovery, the patient is out of bed and
involved in a variety of activities and therapies. It is important to monitor
cardiorespiratory endurance carefully and avoid overtiring the patient. Physical
therapy goals typically include:
• Prevent or minimize secondary complications.
• Compensate for sensory and perceptual loss.
• Promote selective movement control and normalized postural tone.
• Improve postural control and balance.
• Develop independent functional mobility skills.
FIGURE 9.6: Rib cage elevation
FIGURE 9.7: Lower rib cage elevation
• Develop independent activities of daily living.

• Develop functional cardiorespiratory endurance.
• Encourage socialization and motivation.
Let us now consider the general mistakes the people make while carrying
out rehabilitation of a hemiplegic patient.
DO’S AND DON’TS

 Squeeze a ball: “NO”
– Exception: Molding the hand round the cone or a ball (in lumbrical
position), can benefit in shoulder hand syndrome, where there is
hyperextension at MCP joints and reduced web space which results in
useless hand but should evaluate for grasp reflex.
 Monkey poles: “NO”
 Overhand pulley exercises: “NO”
 If hand hurts, it’s doing you good: “NO”
 Parallel bar for walking: “NO”
 Springs, weights help to regain muscle power: “NO”

 Testing of muscle strength: “NO”
 If recovery does not occur in 3–4 months, it is unlikely: “NO”
 Work or try harder: “NO”
– Exception: Only use it carefully to boost the morale.
 Paddling a cycle. “With Caution”
– Exception: Patient who have regained good functional movements.
 Forced passive stretching should be strictly avoided.
 Do not compare two stroke patients.
 Hot water fomentation and diathermy should not be used in patients with
impaired sensations.
 Do not label the patient unmotivated, confused, demented unless properly
assessed.
 Never walk a hemiplegic hanging his sound arm or hemiplegic arm around
assistant’s neck.
Activities in Lying 155
C H A P T E R
10
Activities in Lying
INTRODUCTION
For ease in carrying out the treatment practically, let us now divide the treatment
protocol as per the position in which they are carried out: Lying position,
sitting position and standing position in subsequent chapters.
In the acute stage, all the movements are carried out in lying down position,
as tone of antigravity muscles is not sufficient enough to keep the body in
upright position. Many a times, new activity is taught in lying position as
many of the patients feel unsafe in unsupported position. All the transition
activities from supine to side-lying, side-lying to prone and from lying to
sitting are carried out in lying position. As soon as the patient is able to
sit upright, activities in sitting are started as sitting is a more functional position
of the two.
After moving the patient passively, a more active movement protocol is
employed. Treatment is always started by explaining the patient about the
nature of the movement and its functional outcome. Before the movements
are started, there are a few techniques which inhibit spastic patterns and facilitate
the normal movement patterns, which are explained below.
BRUSHING
Techniques of Rood approach are used at the start of the treatment. Slow
or rapid brushing or stroking can be used for reducing the spasticity or for
excitatory purpose early on as there is a latent period of about few minutes
before the effect starts. That is why Rood’s approach can be used at the beginning
so that the tissues become receptive to the session in which active control
is expected out of it.
Brushing by a small horse hair brush on the desired part is carried out.
Brushing is carried out slowly but firmly, directly on the skin of the corresponding
muscle which is to be stimulated. The sequence can be:
 Extensor aspect of the forearm—from lateral epicondyle of humerus to distal
aspect of wrist joint. It stimulates activity of long extensors of forearm
and wrist and fingers
 From distal aspect of dorsal aspect of the wrist to dorsal tip of all fingers—
stimulates area of the tendons of extensors of fingers and thumb and dorsal
interossie muscles
 On the triceps muscle
 On the abdominal
 From ischial tuberosity to popliteal fossa for knee flexors
 On the lateral aspect of the leg for ankle eversion with dorsiflexion
 Any other group of muscles as and when required.
ICING
Quick icing can immediately stimulate the contraction. There is a controversy
regarding the direction of the stroke of ice whether from distal to proximal or
vice versa, here, the judgment of the practitioner is advocated. Slow icing is used
to decrease the tone of the muscles. Quick icing can be done by using the ice
cube directly on the skin with vary fast strokes. For slow icing on spastic muscles,
usually ice bags are more useful for practical purposes. Quick icing can be carried
out on the parts which were enumerated for brushing also.
Slow icing can be carried out on:
 Flexor aspect of forearm
 Flexor aspect of arm
 Pectoral region, distally
 Anterior thigh for quadriceps overactivity
 Calf area for gastrocnemius overactivity
 Other area, if needed.
Careful assessment of present movement pattern and expected development
of synergistic patterns is expected to be carried out by the therapist before
attempting to use facilitatory or inhibitory techniques.
CONNECTIVE TISSUE RELEASE

Connective tissue release or myofascial release MFR is of valuable help as
an adjunct to the therapy. A general procedure used in patients suffering from
hemiplegia is described here.
A B
C D
FIGURES 10.1A to E: MFR to upper extremity, left hemiplegia
Technique
 Patient lies supine in a comfortable position
 The part to be treated is exposed
 Talcum powder can be used to reduce friction
 Take your 3 fingerbreadths to perform this technique on the patient as shown
in the Figure 10.1A and the pressure is evenly applied by the pulp of the fingers
 Pressure is adjusted so that the patient should not feel the pain as well
as should also not feel ticklish (Figure 10.1B)
 With continuous application of pressure, fingers are slided on the surface
of the patient’s body from proximal attachment of the muscle to the distal
attachment (Figures 10.1C to E).
 This procedure is repeated 3 to 4 times gradually, or as per requirement

 The therapist would ‘feel’ the ‘melting away’ of spasticity as the treatment
is administered
 The patient is made aware of this feeling of relaxation.
Spastic muscles feel ‘hard’ on touch as compared to the muscles having
normal tone. Softening of the muscles on touch, occurs if the tone of the
muscle normalizes. In chronic spastic cases, the superficial and the deep fascia
become adherent to the other structures and it becomes difficult for the patient
to move actively. Connective tissue techniques also helps in such cases.
Nevertheless, few sittings of this technique are required to produce sustainable
results.
Sites of Application (Figures 10.1 to 10.4)

 Sternocleidomastoid, pectoralis major, biceps, brachialis, coracobrachialis,
forearm flexors, and palm with opening of thumb and fingers.
 Quadriceps for extensor thrust, gastrocnemius, plantar aspect of sole of
foot with opening up of great toe and other toes (extension and abduction)
 For patellar tendon and entire quadriceps mechanism, following technique
is useful (Figure 10.2)
– Therapist stands on the affected side (e.g., right) of the patient
– Therapist places the right hand on the patient’s right anteriosuperior iliac
spine (ASIS), and left hand just above the patella, both the hands crossing
each other
– The patella rests between the 1st web space of the therapist
– Thereafter, a gentle force by both the hands is applied in opposite direction
to take away the slack. The hand on the ASIS gives force on the cephalic
direction while the hand on patella gives force in caudal direction
– This force is sustained for 90 seconds, and then gradually released. Usually
3 to 4 repetitions are sufficient.
FIGURE 10.2: MFR to quadriceps, crossed hand technique, left hemiplegia

FIGURE 10.3: MFR to biceps, crossed hand technique, left hemiplegia
FIGURE 10.4: MFR to long flexors, crossed hand technique, left hemiplegia
This technique is also beneficial in releasing the tone in any part of the
body. Apart from quadriceps, it can be easily and effectively applied in the
muscles of arm and forearm as shown in the Figures 10.3 and 10.4. The
force which is applied is just to take up the ‘slack’ in the system and it
should not be more than that otherwise there is a risk of skin of the part
to be stretched, which is not desired.
Benefits
 Body contact imparts tactile stimulation
 The muscle tone normalizes ‘on table’, thus improving its flexibility,
stretchability, contractility immediately
 Decreases the chances of tissue contractures
 As this technique loosens up the fascia, it helps in the entire kinematic
chain function
 Improves the circulation of the part and normalizes the part temperature.
NEURAL TISSUE STRETCH

Prior to exercise program, neural tissue stretch can be beneficial for the ease
of the movement. It decreases the pain and improves active and passive range
of motion. For the upper quadrant, the sequence of movement is:
Median Nerve
 Neck side-flexed and rotated to opposite direction
 Scapula downwards
 Humerus externally rotated and abducted at 90 degrees
 Elbow extended
 Forearm supinated
 Wrist extended
 Fingers extended and opened up and thumb extended and abducted.
Ulnar Nerve
 Neck side-flexed and rotated to opposite direction
 Shoulder externally rotated, abducted at 90 degrees
 Elbow completely flexed
 Forearm pronated
 Wrist extended and radially deviated
 Fingers extended and thumb extended and abducted.
Radial Nerve
 Neck side-flexed and rotated towards opposite direction
 Shoulder internally rotated, and abducted
 Elbow extended
 Wrist flexed
 Fingers and thumb flexed and placed in palm.
The sequence for lower quadrant is:
Sciatic Nerve
 Trunk side-flexed to opposite direction
 Hip medially rotated, flexed and adducted
 Knee extended
For further reading, refer to Butler and Shaklock.

 Ankle dorsiflexed and subtalar joint may be inverted or everted

 Toes extended.
Femoral Nerve
 Trunk side-flexed
 Hip medial rotation, adducted and extended; For hip is externally rotated,
abducted and extended
 Knee flexed
 Ankle plantar flexed
 Toes flexed.
Obturator Nerve
 Trunk side-flexed
 Hip is externally rotated, abducted and extended
 Knee flexed.
For upper quadrant, either lying or sitting position is chosen for the treatment.
For lower quadrant, lying position is the position of choice for ease of application.
The above described positions are used to assess the tension in the neural
mechanism. The patient complains of pain and sometimes paresthesia in any
region along the course of the nerve which is affected. After the assessment
is done and the nerve tissue localized, mobilization in a gentle manner is
carried out step by step. First, proximal parts are mobilized and gradually,
other parts can be added to it. For the purpose of treatment, either proximal
part is kept fixed and distal part is moved or vice versa. The mobilization
which is carried out is of oscillatory in nature. Oscillations are quick and
can be done at a frequency of 1 to 2 per second. If pain is more, the frequency
can be decreased and gradual, sustained mobility is done. Neural tissue
mobilization is also valuable in preventing and breaking the synergistic patterns
of movement.
SUSTAINED STRETCH
After carrying out connective tissue release, sustained stretch technique can
be used if spasticity is still present. Spasticity is velocity dependent, if the
speed of stretch is high, spasticity increases due to stretch reflex. Thus,
for decreasing spasticity and for maintaining stretchability of the muscles,
slow and sustained stretching is advised. In the Figure 10.5 sustained stretch
of the upper extremity is demonstrated. Similarly, sustained stretch of any
FIGURE 10.5: Sustained stretch of upper extremity, left hemiplegia
of the desired part of the body can be done. The end range position is
held for at least 90 seconds for relaxation. It can also be held for 3 to
5 minutes if need be. This technique inhibits the spastic muscles and hence,
antagonistic muscles are facilitated. The new length of the tissue is registered
in the brain and the base line is shifted. In this manner, the new length
of the tissue gets maintained and after a time, the tissue gets used to the
new length and hence, even after the synergistic pattern is activated due
to some reason, the relaxation time taken for the treated tissue is less than
the tissue which is not treated by sustained stretch. The therapist should
take care about the pain during the stretch, if any. Initially, the stretching
pain is common which decreases during the 90 seconds of hold. Sometimes,
the pain may not subside, and in such a case, the sustained stretch is
discontinued till the cause of pain is found out and treated. Pain elicits
the hypertonicity and hence, it is not advisable to elicit any form of pain
during any of the treatment session. Therapy sessions should be enjoyable
to the patient and not stressful or painful. Sustained stretch used in the
synergistic patterns prior to active control exercises will be tremendously
beneficial in providing the quality of the movement. These techniques can
be taught to the patient and patient’s relatives so that, it can be carried
out several times a day. Uses of weight bearing on limbs, standing, wall
stretches, auto-assisted stretches, etc. are different forms of sustained stretches.
PRESSURE OVER BODY PARTS

Application of pressure by the use of a heavy medicine ball can be used
for decrease in spasticity, activation of the proprioception and tactile stimulation.
It is a useful tool at the start of the therapy session. In the Figures 10.6A
and B, a medicine ball of 2 pounds weight is used for the pressure.
Pressure can be applied by any of the technique but in practical purposes,
A B
FIGURES 10.6A and B: Applying pressure over upper extremity by medicine ball,
left hemiplegia
ball is most user-friendly as it can roll freely on the body surface. Application
of the pressure can be done by the therapist all over the body (including
trunk and chest) on the affected side. In patients with sensory problems, pressure
is applied first on the unaffected side to get the ‘feel’ of the procedure. Patients
can also be taught to apply pressure with a ball themselves using their normal
upper extremity to improve sensory perception.
SELECTIVE TRUNK ACTIVITY

By studying the pathological manifestation in the periphery, we can realize
the significance of sound middle or center part of the body, that the functional
movements must have a healthy center and the key is the trunk for the
performance of various functional movements and skillful activities economically,
with ease and speed and for normal head and neck orientation in space. Bobath
concept has stressed the importance of the trunk and its rotation as a key
to reducing spasticity in the proximal areas and progressing to inhibit in distal
parts. Selective truncal activity is a prerequisite to standing, walking, to turn
in bed, in moving between lying and sitting, and sitting to standing. All these
movements involve muscle activity in relation to the pull of gravity. Sitting
to standing activity that is performed numerous times a day, is the most
challenging, requiring shifting the body mass against the pull of gravity over
to the feet for the maintenance of balance. This activity recruits extensor muscles
in the trunk and the lower extremities.
Our upright posture, narrow base and freedom of upper extremity movements
demand a stable and yet a mobile trunk. The pelvic girdle forms a stable
base for the long moving lever of the vertebral column in upright postures
against gravity. The connection between the trunk and the upper extremities
is quite different. The scapula floats in a muscular suspension to permit great
ranges of movements at the glenohumeral joints. It provides stability for the
grasping and prehensile hand functions. The shoulder girdles have no direct
articulation with the vertebral column, arms are freely mobile to explore and
experience the environment from early childhood. The vertebral column must
have a very finely coordinated muscle activity for the stability and mobility
against gravity. The body moves forwards, backwards and sideways and the
precise muscles must be activated to prevent falling in the direction of the
gravity. All movements of the spine require muscle activity to oppose the
pull of gravity. The therapist must have a thorough knowledge of the truncal
mechanics to selectively activate the desired muscles in relation to the pull
of gravity. The ideas of the bridge and the tentacle (Kleinvogelback, 1990)
will help to clarify the analysis of muscle activity.
Bridge is formed when two parts of the body hold the arch; the muscles
on the underside of the arch maintain the bridge.
Tentacle moves against the gravity, distal part is free, as in open chain
lower limb movements.
Problems associated with loss of selective trunk activity are:
 Breathing
 Inability to come to sitting from lying
 Difficulty associated with maintenance of balance in sitting, standing and
walking
 Loss of shoulder girdle activity.
CORRECTION OF ANTERIOR CHEST

POSITION IN LYING
Before the actual active movement pattern activities are started, position of
the patient is aligned in midline. Any excess tone in the neck and scapular
muscles is reduced. The neck is kept neutral in relation to the thorax. As
the Figure 10.7 suggests, the tip of the shoulders are held in the position
by applying adequate pressure. The palm of the therapist’s hand should push
the distal end of clavicle and acromioclavicular joint downwards. The hands
should not push the head of the humerus as this may result into subluxation
of the glenohumeral joint. This procedure is carried out on both sides for
symmetry of the body parts. Gentle oscillatory motion in downwards direction
may be necessary for a few times before obtaining a substantial symmetry.
This procedure stretches sternocleidomastoid muscle to some extent and is
helpful in stretching of upper trapezius muscle on both the sides. The thorax
thus is ready for further activation.
FIGURE 10.7: Aligning tips of shoulder, left hemiplegia
RIB CAGE ALIGNMENT

As earlier explained, the rib cage may be elevated and flared outwardly due
to the loss of tone on the affected side. As shown in the Figures 10.8A and
B, the rib cage alignment is first assessed on both the sides and correction
is made on both the sides by pushing the rib cage down and inwards. This
position is held for a few seconds and is repeated for several times. This
procedure facilitates the contraction of intercostal muscles and abdominal
muscles, stretches the fascia on the anterior aspect of neck and thorax and
help to stretch the anterior muscles. It improves conduciveness of the anterior
structures for stretching and hence, active activation. The scapular alignment
is facilitated due to alignment of the thorax and thus indirectly, the shoulder
functions are facilitated.
If during any of the active movements, the rib cage gets elevated, it can
be held down by the unilateral pressure on the affected side till the active
control is achieved by the patient. During this procedure, patient is constantly
asked to keep the attention on the direction of the movement for faster learning.
MOBILIZATION OF THORAX
The position for mobilization of the thorax in lying is as shown in the Figure
10.9A. The therapist cradles the patient’s hemiplegic upper limb as shown.
The therapist then assists the patient to flex and rotate while the patient keeps
the head off the couch. This is important because if the patient is keeping
the head down, extensor tone may take over rendering the activity useless
as we are working towards the activation of the flexion pattern which is
A B
FIGURES 10.8A and B: Pushing the ribcage down and inward, left hemiplegia
A B
FIGURES 10.9A and B: Mobilization of thorax, left hemiplegia
antagonistic to the abnormal total extensor pattern. Gradually, the assistance

by the therapist is reduced till the patient is able to carry out the movement.
The therapist may have to stabilize the thorax with one hand if the rib cage
gets elevated or if the lumbar spine starts flexing due to stiff thorax, as shown
in the Figure 10.9B.
The Figure 10.10 shows the active progression with the flexion of thorax
along with the activation of lumbar flexion, recruiting the abdominal muscles.
Notice the position of the head and neck flexion. Notice the position of the
scapular forward rotation and protraction recruiting serratus anterior and
pectoralis major and minor. The upper limb may be assisted by the therapist
from the wrist and fingers, till the active upper limb holding is possible.
MOBILIZING THE ARM

A stiff painful arm impedes balance and movement of the whole body, limits
treatment and interferes with daily living. If full passive elevation of the arm
FIGURE 10.10: Active mobilization of thorax with upper limb and abdominal activation,
left hemiplegia
is performed everyday, the complications may never arise. The movement should
be performed in such a way that no pain is elicited. Pain around the shoulder
would indicate that sensitive structures around the joint were being compromised
(Davies, 1985).
Elevation of the Arm

Maintaining lateral rotation at the shoulder, the elbow is extended, and the
arm lifted into full elevation with supination of the forearm, extension of
the wrist and fingers and wide abduction of the thumb (Figures 10.11 and
10.12).
Mobilization of upper limb is begun in an active fashion by a technique
of placing. Initially, an appropriate position is selected and assistance is given
to achieve that position. Then after, assistance is reduced and patient is asked
to actively hold the position. As shown in the Figures 10.13A to C, a position
of shoulder flexion and external rotation is selected and elbow is kept extended.
Wrist and fingers are kept extended. The patient is asked to actively hold
the position. This way, functions of upper limb can be achieved in varieties
of ways. Different angles of motions are selected and desired results can be
achieved.
The arm is moved until it will stay in elevation without pulling down into
flexion. Care must be taken not to drop the arm before any of the active
control is developed. Arm should never be allowed to go into abduction as
it will elicit abduction of the arm along with the internal rotation of the shoulder
which is not desirable.
FIGURE 10.11: Mobilization of upper limb in RIP, left hemiplegia
FIGURE 10.12: Grip for mobilization, left hemiplegia
A B
C D
FIGURES 10.13A to D: Active assisted mobilization of upper limb, left hemiplegia
FIGURE 10.14: Bilateral symmetrical pattern of movement in upper limbs, left

hemiplegia
From full elevation, the arm is taken out to the side in abduction and
up again maintaining the external rotation of shoulder, extension at the elbow,
fingers and wrist with supination of the forearm.
After achieving the active control of upper limb in lying, bilateral symmetrical
movements are started as shown in the Figure 10.14. The elbows are actively
extended on both the sides and assistance is given as and when required.
The bilateral symmetrical movements facilitate the adequate control in the
affected limb. During this procedure, the thorax is actively stabilized and
contraction of abdominals is achieved by active posterior pelvic tilt by keeping
the lumbar spine touched to the couch. Lower limbs can assume a position
of flexion at knee and hip (crook lying) initially progressing to lower limbs
extension.
PROPRIOCEPTIVE NEUROMUSCULAR
FACILITATION (PNF) PATTERN ACTIVITIES
Movements can be carried out in proprioceptive neuromuscular facilitation
(PNF) patterns. Facilitation is carried out in entire pattern of activity or the
patterns can be broken up into segments and hence, concentration on individual
movement can be gained. Example of the pattern of activities can be:
Starting position:
 Shoulder: Extension, adduction, internal rotation
 Elbow: Flexion
 Radioulnar: Pronation
 Wrist: Ulnar deviation, flexion
 Fingers: Flexion
 Thumb: Flexion, adduction
End position:
 Shoulder: Flexion, abduction, external rotation
 Elbow: Extension
 Radioulnar: Supination
 Wrist: Radial deviation, extension
 Fingers: Extension
 Thumb: Extension, abduction
Other patterns which can be used are:
Shoulder flexion, adduction, internal rotation, with elbow flexion and supination,
wrist and fingers flexion, thumb flexion and adduction, as a starting position
to the end position of shoulder extension, abduction, external rotation, with
elbow extension and pronation wrist and fingers extension and thumb extension
and abduction.
Any of the PNF patterns can be used with a variety of combinations. The
ultimate goal of achieving normal functional movement patterns is always
kept in mind while choosing the activity pattern. For an example, if tone
in elbow extensor is higher than that of the flexors, then a pattern with elbow
flexion can be selected. Many such combinations can be made by judicious
use of the patterns. Initially, assistance from the therapist may be needed for
completion of the task. Techniques like stretch reflex, quick stretch, and
irradiation may be used as and when required. In later stages, according to
strength of individual muscle and comparative strength of the muscle in a
movement pattern, resistance to the individual part or entire pattern can be
given. After the session, the tone of the muscles is checked for and if hypertonia
occurs, the effort on the part of the patient is decreased in the subsequent
sessions.
SIDE-LYING ACTIVITIES
Activities in side-lying can be started as soon as possible. As explained earlier,
total flexion pattern is used while turning to any side. While turning to hemiplegic
side, the use of normal lower limb extension as in ‘pushing’ as well as normal
side upper limb pushing is not allowed. Also, while turning to normal side,
pushing with extensor thrust of hemiplegic lower limb or ‘pulling’ from normal
upper limb is not allowed (Figures 10.15A and B). Instead, a total flexion
pattern is used for turning by activation of trunk flexors and counteracting
extensor thrust.
Correct rolling brings awareness of the affected side, release of spasticity
by rotation between the shoulder girdle and pelvis and facilitates active movement
in the trunk and limbs.
B
FIGURES 10.15A and B: (A) Turning to sound side using total flexion pattern,
right hemiplegia; (B) Turning to affected side, right hemiplegia
To the Affected Side

With the affected arm in abduction, the patient is asked to lift the head and
bring the sound arm across to touch the other hand, pushing off the bed.
To the Sound Side

The patient’s affected leg is guided over his other leg with less and less assistance
until the patient can perform the action himself. The patient can clasp both
hands together and rotates the upper trunk by moving both arms to the sound
side. Rolling should be encouraged in both directions, onto the sound side
to promote early independence and onto the affected side to encourage functional
reintegration of the hemiplegic side. Extremity movement patterns can facilitate
improved rolling through momentum and the fostering of segmental trunk
rotation patterns. With both hands clasped together in a prayer position, the
patient can actively assist flexion and upper trunk rotation onto a side lying
on elbow posture.
During early transfers, the patient may be more or less a passive participant.
Adjusting the hospital bed to the height of the chair or wheelchair will help
to ease the transfer. Staffs often emphasizes the sound side by placing the
chair to that side and having the patient stand and pivot a quarter turn on
the unaffected leg before sitting down. While this technique promotes early
and safe independence in transfers, it neglects the affected side and may make
subsequent training more difficult. The patient should be taught to transfer
to both sides early on.
Transferring to the hemiplegic side may be more difficult at first but will
assist in overall re-education and reintegration of the two sides of the body.
When transferring, the patient’s affected arm can be stabilized in extension
and external rotation against the therapist’s body. Alternately, the patient’s
arms (hands in prayer position) can be placed to one side on the forward
weight shift by using manual contacts, either at the upper trunk or pelvis.
The affected leg may be stabilized by the therapist’s knee exerting a counterforce
on the patient’s as needed.
As shown in the Figures 10.16 and 10.17, the side-lying to affected side
with the arm at 90 degrees will facilitate external rotation at shoulder and
eventually supination of forearm, extension of elbow and hence, will facilitate
the movement of wrist and fingers extension.
The side-lying position is also useful for the selective elbow flexion and
extension (Figure 10.18). In this position, the shoulder is in a fixed position
of external rotation and abduction. The force of the contraction is concentrated
upon the elbow and the radioulnar joints. Firstly, supination is tried and
keeping the forearm supinated, elbow flexion is gradually carried out. Then,
it is gradually lowered towards extension. Care must be taken not to allow
the jerky movements to take place. The eccentric lowering of the forearm
in extension will promote a good facilitation to active extension of elbow
joint in more functional position of sitting and standing. The patient can
visualize their own upper limb moving which will provide with a visual
biofeedback.
SCAPULAR MOBILIZATION
Scapular control is extremely valuable in rehabilitation and functional recovery
of hemiplegic upper extremity. Initially, the scapula is kept mobile passively.
Gradually, as the tone of the muscle starts developing, more active protocol
is incorporated. As with all the activities, the addition of adequate and optimum
resistance will further more improve the function. The position of glenoid
FIGURE 10.16: Weight bearing on affected side with reach outs using sound arm,
left hemiplegia
FIGURE 10.17: Shoulder external rotation with forearm supination in side-lying,

left hemiplegia
FIGURE 10.18: Selective elbow flexion, extension in side-lying, left hemiplegia

FIGURE 10.19: Scapular muscles from front
FIGURE 10.20: Scapular muscles from behind
cavity in relation to the head of humerus is vital for the functioning of the
shoulder movements and hence the functioning of the entire upper extremity.
As it is well known that the shoulder complex is dependent on the muscle
activity only and the glenohumeral joint has compromised stability in gaining
mobility. This stability is provided by the rotator cuff muscles and other joint
structures. Thus, strengthening of rotator cuff muscles and the muscles of
entire shoulder complex is vital in upper extremity rehabilitation (Figures 10.19
and 10.20). The muscles which need special attention are:
 Upper trapezius
 Middle trapezius
 Lower trapezius
 Serratus anterior
 Rhomboids major
 Rhomboids minor
 Teres major
 Teres minor
 Latissimus dorsi
 Subscapularis
 Supraspinatus
 Infraspinatus
 Pectoralis major
 Pectoralis minor
 Deltoid—all fibers
To start with, ‘scapular clock exercises’ can be given to the patient.
Posterior Depression
These activities are done initially passively or with optimum assistance and
gradually progressed to active contractions in the specified direction or resisted
at a later stage. The position of the therapist is behind the patient initially
to get a full view of the moving scapula. As such, any part which is moved
is to be exposed for proper visualization of the part, but in case of scapular
activities, it becomes more important as scapular movements are difficult to
exercise with the clothes on. Right hand of the therapist is placed on the
tip of the shoulder as shown in the Figure 10.21 and the scapula is moved
posteriorly and downwards. Other hand of the therapist stabilizes the thoracic
cage and trunk for avoiding trick movements. End position is shown in the
Figure 10.21. Figure 10.22 shows the scapular activity during upper extremity
movement.
 Muscles activated:
Serratus anterior—lower portion
Rhomboids major and minor
Latirsimus dorsi
Anterior Elevation
Scapula is moved anteriorly and in elevation. The position of the hands is
similar, but the direction of the movement and resistance is adjusted according
to the end movement. The Figure 10.23 shows the end movement. Figure
10.24 shows the scapular activity during upper extremity movement.
FIGURE 10.21: Scapula—posterior depression
FIGURE 10.22: Scapula—posterior depression, entire upper limb PNF
FIGURE 10.23: Scapula—anterior elevation

FIGURE 10.24: Scapula-anterior elevation, entire upper limb PNF
Anterior Depression
– Rhomboids
– Serratus anterior—upper portion
– Levator scapulae
– Pectoralis minor
The scapula is moved anteriorly and downwards. For the ease of application,
the therapist may stand on front of the patient but care should be taken to
visualize the movement for accuracy of treatment.
The Figure 10.25A shows the end position. Figure 10.25B shows the scapular
activity during upper extremity movement.
A B
FIGURES 10.25A and B: (A) Scapula—anterior depression, (B) scapula—anterior
depression, entire upper limb PNF
Serratus anterior
Pectoralis major
Pectoralis minor
Rhomboids
Posterior Elevation
The scapula is moved posteriorly and upwards. Figure 10.26A show the end
position and Figure 10.26B shows the scapular activity during upper extremity
movement.
A B
FIGURES 10.26A and B: (A) Scapula-posterior elevation, (B) scapula-posterior
elevation, entire upper limb PNF
Trapezius
Levator scapulae.
Workout for Serratus Anterior
Important muscles like serratus anterior is rehabilitated specifically from the
initial stages itself. The protocol of progressing from assisted to active and
then to resisted workout is followed throughout. The position which is shown
in the Figures 10.27A and B can be used both for assisted as well as resisted
workout.
Note the position of left hand of the therapist which is palpating the lateral
aspect of scapula. The serratus anterior can also be rehabilitated in side-lying
position.
Workout for Middle Trapezius
Note the position of external rotation of the shoulder during trapezius workout
in the Figure 10.28. The upper limb is horizontally abducted at 90 degrees.
A B
FIGURES 10.27A and B: Workout for serratus anterior in lying
FIGURE 10.28: Workout for middle trapezius in prone-lying
Workout for lower trapezius

The upper limb is horizontally abducted and flexed in scaption (Figure 10.29).
FIGURE 10.29: Workout for lower trapezius in prone-lying

Workout for Subscapularis

In the position of extension and internal rotation of shoulder, the elbow
is taken in the direction of the roof. Resistance can be added in the later
stage (Figure 10.30).
The workout of the muscles like trapezius and subscapularis in the open
kinematic chain is difficult for the patient in the initial stages due to either
hypotonia, or in the later stages by hypertonia. Thus, it is advised to carry
out the scapular muscle activation from the earlier stages itself, in close chain
and then moving towards open chain activities. This would ensure a smooth
rehabilitation of the upper extremity.
FIGURE 10.30: Workout for subscapularis in prone-lying
ACTIVATION OF LOWER TRUNK

For activation of lower abdominals, obliques, and stabilizers like transverse
abdominis, lying position is useful in the initial stages. In the same position,
resistance can be used to strengthen the muscles. As in the Figure 10.31A,
both legs of patient are flexed at the hip and the knee and ankles are kept
neutral. The trunk is flexed by asking the patient to take the buttocks off
the couch. Patient is asked to keep the head stable. Assisted/resisted rotation
on either side is carried out to rehabilitate obliques. This technique counteracts
the extensor thrust of the spine.
Figure 10.31B shows the extreme position of flexion and rotation of the
lower abdominal region.
Hemiplegic leg of the patient is crossed on the sound leg which is in crook
position. As in the Figure 10.32, the hemiplegic side is left. The patient is
asked to maintain the position. The pelvis is kept posteriorly tilted by keeping
lumbar spine flat on the couch (lumbar lordosis obliterated). Next step is
to rotate the trunk to left and then to the right by moving the leg. Note the
position of the therapist’s right hand which is on patient’s left knee. This
A B
FIGURES 10.31A and B: (A) Activation of lower abdominals, left hemiplegia; (B)
Flexion and rotation of trunk with lower limbs flexed, left hemiplegia
FIGURE 10.32: Abdominal activation, left hemiplegia
hand assists, controls as well as resists the motion of rotation while the left
hand palpates the quality of the abdominal muscle contraction.
Figure 10.33 shows rotation towards right. Note the increase in lumbar
lordosis which should be prevented.
Figure 10.34 shows rotation towards left. Note the position change of
therapist’s right hand. The left hand of the therapist constantly palpates the
contracting muscles.
Extreme position of rotation will force the therapist to stabilize the upper
trunk on the right side to ensure only the lower trunk rotation. All the above
mentioned activities can be resisted to strengthen the muscles. Slight modification
in the position may be required for practical purposes (Figures 10.35).
Furthermore, the sound upper limb is held in 90 degrees flexion as shown
in the Figure 10.36. The active holds of the sound limb will elicit the contraction
of thoracic area. By this activity, active stabilization of thorax is achieved
along with the contraction of upper abdominal muscles which work as stabilizers.
FIGURE 10.33: Abdominal activation with crossed legs with trunk rotation to right,
left hemiplegia
FIGURE 10.34: Abdominal activation with crossed legs with trunk rotation to left,
left hemiplegia
FIGURE 10.35: Extreme position of rotation, left hemiplegia

FIGURE 10.36: Abdominal activation with stabilization of thorax using sound upper
limb, left hemiplegia
Figure 10.37 shows the incorrect method of bridging. The patient uses the
force of hip extensors rather than abdominals for lifting the pelvis off the
couch. This can be noticed by increase in the amount of lumbar lordosis.
The correct position of bridging with posterior pelvic tilt by using the muscle
force of abdominals is shown in Figure 10.38. This is the correct position
of bridging activity and should be always encouraged from the initial stages.
FIGURE 10.37: Incorrect method of bridging, left hemiplegia
FIGURE 10.38: Correct method of bridging, left hemiplegia

Notice the contraction of abdominals in the Figure 10.38. The patient is left
sided hemiplegic.
Progression in bridging is made by elevation of sound upper limb and
sound lower limb, simultaneously. This will provide strong contractions of
trunk muscles (Figure 10.39). Note the active maintenance of posterior pelvic
tilt throughout the movement. Extra undue effort on the part of the patient
will increase the spasticity on the affected side and hence, care is taken to
check affected limbs while carrying out this activity. If the tone on the affected
side increases, either limbs are kept in reflex-inhibiting postures or the grade
of effort is reduced.
Rhythmic knee flexion and extension with hip and pelvis fixed is practiced
for the total weight bearing on the affected limbs and this is useful functionally
in activities like moving, sitting and stance phase of walking (Figures 10.40
to 10.42).
Bridging activities develop pelvic control, advanced limb control (hip
extension with knee flexion, foot eversion), and early lower extremity weight
bearing. Bridging activities should include assisted and independent assumption
of the posture. If the affected lower extremity is unable to hold in a hook-
lying position, the therapist will need to assist by stabilizing the foot during
A B
FIGURES 10.39A to C: (A) Bridging with both upper limbs held in flexion, right
hemiplegia, (B) unilateral bridging with weight bearing on hemiplegic side, right
hemiplegia and (C) unilateral bridging with weight bearing on sound side, right
hemiplegia
the bridge activity. Care should be taken as bridging activates the trunk extensors,
if there is a lack of abdominal control for posterior pelvic tilts. Assistance
for the posterior tilt maintenance for bridging should be given by the therapist
till the active control develops.
FIGURE 10.40: Unilateral bridging with thoracic stability, left hemiplegia
FIGURE 10.41: Unilateral bridging with dynamic activities, left hemiplegia
FIGURE 10.42: Unilateral bridging with resistance, left hemiplegia

FIGURE 10.43: Unilateral bridging with the control of lower extremities, left hemiplegia
Affected lower limb is raised with knee in flexion while the sound upper
limb is lifted up (Figures 10.42 and 10.43). The contralateral action is useful
in reactions of pelvis during activities of turning and walking. Initially, the
therapist may have to assist the pelvis in upward direction and prevent it
from falling off. Later on, the same grip can be changed to resist the upward
movement of pelvis.
Elongation of the Trunk

The patient lies in half crook-lying with his affected leg flexed and adducted.
Place one hand on his pelvis, the other hand over his shoulder and elongate
his trunk until the hip remains forward off the bed (Figure 10.44).
FIGURE 10.44: Elongation of the trunk, left hemiplegia

Movement of the Scapula

One hand is placed over the scapula, the other supporting his arm (Figure
10.45). With the shoulder protracted, the scapula is elevated and depressed
until spasticity is released and it moves freely. While the scapula is being
moved, the arm is eased into lateral rotation.
FIGURE 10.45: Mobilization of scapula in side-lying, left hemiplegia
LOWER EXTREMITY CONTROL

Training of the lower extremity essentially prepares the patient for ambulation.
Pre-gait mat activities should concentrate on working muscles in the appropriate
combinations needed for the gait. For example, hip and knee extensors need
to be activated with abductors and dorsiflexors for early stance. Strong synergy
combinations also need to be broken up. A variety of activities can be used,
including bridging, supine knee flexion with hip extension over the side of
the mat, or standing modified plantigrade with knee flexion. Hip adduction
should be stressed during flexion movements of the hip and knee, while abduction
should be stressed during extension movements (e.g. supine, PNF D1 lower
extremity diagonal; sitting, crossing and uncrossing the hemiplegic leg). Pelvic
control is important and can be promoted through lower trunk rotation in
a number of postures (e.g. side-lying; supine, modified hook-lying with the
hemiplegic leg pushing off; kneeling; or standing).
An effective progression increases the challenge to the patient gradually
by modifying postures until synergy influence is completely lacking (e.g. hip
abduction can be performed first in hook-lying, then supine, side-lying, modified
plantigrade and standing positions). Contraction patterns should also be varied.
Thus, dorsiflexors can be first activated in a sitting posture by using first
a holding contraction, then an eccentric letting go, and finally a shortening
contraction. This stimulates the functional expectations of normal gait cycle
as the foot goes in swing phase through stance.
Voluntary control of eversion is often difficult to achieve, since these muscles

do not function in either synergy. The application of stretch and resistance
to these muscles during a pattern that activates dorsiflexors may be effective
in initiating a response. Postural challenges may also elicit these muscles
automatically, even though voluntary control is lacking. Control of knee function
is also problematic. Reciprocal action should be stressed early, beginning first
in sitting, then in supine hook-lying, prone, modified plantigrade, or supported
standing positions, and progressing to standing and walking. Dissociation of
arm movements during lower extremity training is also an important consideration
and may be achieved through the use of pre positioning and voluntary control
(e.g. having the patient hold clasped hands together overhead in a “prayer
position”, during a lower extremity activity).
Since most patients regain some use of their lower extremities early in
recovery, range of motion techniques should focus on specific areas of deficit.
For many patients, the foot and ankle control remains limited and tone quickly
progresses from initial flaccidity to spasticity, typically in the plantar flexors
(Figure 10.46). Techniques are designed to elongate plantar flexors through
slow, maintained stretch and to activate weak dorsiflexors, thereby reciprocally
inhibiting plantar flexors, may prove more successful than straight passive
ROM. Thus, weight bearing and rocking in modified plantigrade or prolonged
static positioning using adaptive equipment (i.e. tilt table with toe wedges)
can gain motion while inhibiting spastic plantar flexors. Johnstone suggests
using orally inflated pressure splints to maintain limbs in antispasm positions
and to promote sensory re-education. To prevent associated reactions, the hands
can be clasped in elevation or, preferably, the patient can learn to inhibit
the reaction by letting the arm remain relaxed at the side.
FIGURE 10.46: Plantar flexion in prone lying, left hemiplegia

Hip and Knee Flexion over the Side of the Bed

Place the leg of the patient over the side of the bed with the hip extended
and hold the knee in flexion and the foot in full dorsiflexion until there is
no resistance. Maintain the position of the foot and knee and guide the leg
up on to the bed while the patient actively assists (Figures 10.47A to C).
Repeat the movement preventing any abnormal pattern occurring, e.g. extension
of the knee or lateral rotation of the hip. If the exercise is perfected, the
patient will be able to bring the leg forward when walking and climb stairs
in a normal manner, one foot after the other.
A B
C
FIGURES 10.47A to C: Training for taking the hemiplegic leg up on the couch,
right hemiplegia
Knee Extension with Dorsiflexion

The foot is held in dorsiflexion, and patient’s leg is moved from full flexion
into extension without the toes pushing down and without rotation at the hip.
The patient takes the weight of his limb, making it feel light throughout.
The similar activity can be carried out with the patient’s affected heel resting
on a ball as shown in the Figure 10.48. The patient tries to dorsiflex the
ankle with moving the hip and knee in flexion and then gradually returns
to a position of hip and knee extension keeping the ankle dorsiflexed throughout.
If the ankle starts moving in plantar flexion, the patient immediately controls
the movement actively.
FIGURE 10.48: Counteracting extensor thrust dynamically, left hemiplegia
Hip Control with the Foot on the Bed

In crook-lying, the patient moves alternate knees smoothly into medial and
lateral rotation without the other leg moving and without tilting the pelvis
(Figures 10.49A to C).
A B
C
FIGURES 10.49A to C: (A and B) Selective training for hip rotation while the foot
maintained on the couch, right hemiplegia (C) control maintained by affected side
while the sound side is moving
Hip Control with the Hip in Extension

In half crook lying with affected leg flexed and adducted the patient lifts
affected hip forward off the bed and, maintaining hip flexion, moves knee
out and in.
Independent Movement of the Legs

To prepare for walking, teach the patient to move the legs without moving
the trunk, one leg at a time, asking to make it feel light by taking the
weight himself. They must maintain control while the leg is lowered on
to the bed. The patient is asked to keep his trunk still and not to lean back
throughout the activity. Controlled movements of the leg can be achieved
by asking the patient to hold the limb in various positions in which the
therapist puts (Figures 10.50A and B) where the therapist puts the patient’s
affected lower limb in a position of knee flexion with hip in flexion and
asks the patient to hold the position. As a part of progression, the hip can
be held actively in flexion while the movements of knee flexion and extension
can be practiced for increase in motor control. Use of a ball can give a
dynamic base for moving the leg. The patient can either use it for assistance
as it can decrease friction of leg with the couch or can use as a means
of achieving eccentric control as the ball has to be controlled when moving
in gravity (Figure 10.51).
Contralateral movements with the sound lower limb and affected upper
limb held steady in elevation. Note the quality of trunk muscles contractions.
A B
FIGURES 10.50A and B: Controlled movements of lower limb in lying, left hemiplegia
FIGURE 10.51: Control of lower extremities, left hemiplegia

The affected lower limb, left as in the Figure 10.52, is bearing full weight
even as the pelvis is lifted off the couch and is posteriorly tilted.
Once there is some amount of active contractions in the lower limbs, usually,
all the movements follow the synergistic patterns of extensor thrust, if the
patient is left unattended to. To counteract the effect of strong extensor thrust,
it is always better to start the proceedings initially as prevention is better
than cure. Guidance from the sound lower limb as well as from the therapist
is given. Therapist stands at the foot end of the patient in the middle. Both
the lower limbs of patient are held in semiflexed position at hip and knee
as shown in Figure 10.53. The therapist holds patient’s foot which is maintained
in dorsiflexion at ankles and extension at toes.
FIGURE 10.52: Activation of trunk muscles in bridging with contralateral extremity

patterns, left hemiplegia
FIGURE 10.53: Controlled bilateral lower limb movements in lying, left hemiplegia
A B
FIGURES 10.54A and B: Controlled bilateral lower limb movements in lying, left
hemiplegia
Patient is instructed to keep lumbar spine flat on couch by contraction

of abdominals. Both the lower limbs are moved in a cyclic fashion with the
therapist assisting and guiding the movements on both the sides. Gradually,
the patient actively moves the sound limb in a rhythmic fashion, while the
therapist only guides. On the affected side, however, more assistance may
be required to maintain the position. During the movement, both the limbs
are not allowed to extend from the knee completely (Figures 10.54A and
B). This elicits the contractions of quadriceps muscle eccentrically and gradual
release of quadriceps as well as gluteus maximus muscles, is helpful in
counteracting extensor thrust. Gradually, as the patient progresses, amount
of assistance and henceforth, guidance can be decreased till the patient actively
controls the limb in full range of motion. During this movement, the hip
joint is held actively in neutral rotation. For this, the patient is instructed
to keep the knee in center of the plane of movement and not allow the knee
to drop either to right or to the left i.e., no amount of hip rotation. This
elicits the control of hip rotators, abductors, adductors and extensors which
will be of vital importance during every phase of the gait cycle. Patient should
always watch the moving limbs throughout.
The Figures 10.55A and B show full weight bearing on the left side of
the body which is affected side and actively lifting the pelvis off the couch.
This activity may be difficult for most of the patients and hence, assistance
to the pelvis may be used in upward direction. This movement strengthens
side-flexors of trunk, latissimus dorsi, and lateral muscles of hip. Stabilizers
of thorax, rotator cuff muscles and stabilizers of neck and head also get
strengthened.
B
FIGURES 10.55A and B: Pelvic raising sideways with weight bearing on affected
side, left hemiplegia
Trick motion of pelvis rotation to either direction and use of excess movement
at hip is counteracted by the watchful therapist through proper holds. If any
synergistic pattern is getting elicited in the limbs, the limbs are held in reflex
inhibiting postures, and here, the judgment of the therapist is advocated.
ELONGATION OF TRUNK AND

PELVIC CLOCK EXERCISES
Figure 10.56 shows the method of elongation of trunk on the hemiplegic
side. Here in this case, the left side is the hemiplegic side. The patient
turns to the sound side and thus the hemiplegic side is kept up. A small
pillow is kept below the thoracolumbar region as shown in the Figure 10.56.
Both the knees of the patient are kept slightly flexed to avoid the toppling
off of the patient on either side. Right hand of the therapist is kept on
the left iliac crest and left hand crosses the right and is kept either at lower
border of scapula or at mid scapular region. ‘Slack’ in the system is taken
up and a gradual force is applied so that side-flexors of the trunk are stretched.
By using the same grip and position, rotation of the trunk can also be mobilized.
FIGURE 10.56: Elongation of trunk in side lying, left hemiplegia
Anterior Depression
As with the scapula, the pelvis can also be mobilized in the combination
of movement patterns preferably in side-lying position. These patterns help
in normalizing the gait faster and dynamic postural reflexes are trained. Figure
10.57 shows the anterior depression of pelvis. This is useful in stance phase.
A logical progression of passive, assisted, guided, active and resisted workout
is used. Grip of the therapist may vary accordingly. For assisted workout
as shown in the Figure 10.57, the therapist may stand behind the patient
diagonally. The therapist assists the patient’s pelvis anteriorly and in downward
direction. Other hand of the therapist stabilizes the trunk at lower costal margins
as shown.
FIGURE 10.57: Anterior depression of pelvis, left hemiplegia
Posterior Elevation
Posterior elevation of pelvis is used in terminal stance and initial swing phase
of the gait cycle. Here, the pelvis is moved posteriorly and in upward direction
(Figure 10.58).
FIGURE 10.58: Posterior elevation of pelvis, left hemiplegia
Anterior Elevation
In anterior elevation of pelvis, the therapist guides and later resists the motion
of pelvis anteriorly and upwards. Stability is carried out as already explained
before (Figure 10.59).
FIGURE 10.59: Anterior elevation of pelvis, left hemiplegia
Posterior Depression
In posterior depression, the therapist guides and later resists the motion of
pelvis posteriorly and in downward direction (Figure 10.60).
FIGURE 10.60: Posterior depression of pelvis, left hemiplegia

All the above mentioned activities are of utmost importance during entire
gait cycle. All the motions occur as a single series and hence, description
of individual motion during gait is a futile activity, as the gait is a constant
phenomenon and we have divided it into phases for our convenience in
explanation.
USE OF THE BALL IN TRAINING LOWER

LIMB AND TRUNK IN LYING
The vestibular ball is very useful in training as it provides a dynamic surface
to move as well as dynamic support at the same time. Eccentric training and,
training for timing of contraction is best done with the vestibular ball. Activities
described in this section can be done either on the couch or on the mat.
While in the initial stages, it would be difficult for the patient to assume
lying position on the mat, the exercises with the ball on the couch can be
started right from the beginning. The patient lies comfortably in supine position.
A vestibular ball of optimum size is kept below the lower limbs as shown
in the Figures 10.61A and B. Care must be taken so that the knee joints
of the patient do not fall into hyperextension, for this, knees may be kept
in few degrees of flexion. After this the patient is instructed to carry out
FIGURE 10.61A: Controlled trunk rotation to right using vestibular ball, left hemiplegia
FIGURE 10.61B: Controlled trunk rotation to left using vestibular ball, left hemiplegia
rotation of the trunk by moving the ball to both sides. This activity is helpful
in training abdominals and lower limb control. Assistance may be required
in the initial stages. Later on, resistance to motion on both the sides can
be given manually (Figures 10.62A and B).
A B
FIGURES 10.62A and B: Controlled trunk rotation with pelvic lifts, left hemiplegia
In the same position of the lower limbs, with the extreme rotation, the
patient is asked to raise the pelvis and rotate to same side to aid rotation
at higher level.
To gain control of lower limbs, the affected lower limb, left in this case
is kept actively stabilized on the ball while the sound limb performs abduction
and adduction of hip with knee kept in slight flexion (Figures 10.63 and
10.64). The same procedure can be carried out by the affected limb too.
For progression, a ball is held between both the hands and is held above
in elevation as shown in the Figures 10.65A and B. This procedure actively
involves the stability of shoulder and thoracic region. The lower limbs are
moved alternatively as in previously described activity. Assistance is provided
to the affected limb whenever required and limbs are not allowed to fall prey
to exaggerated and synergistic patterns of activity. Speed of the movements
A B
FIGURES 10.63A and B: Movement of sound limb while the ball is controlled
by affected limb, left hemiplegia
FIGURE 10.64: Movement of sound limb while the ball is controlled by affected
lower limb, with a ball held by hands for thoracic and scapular stability, left hemiplegia
A B
FIGURES 10.65A and B: Movement of affected lower limb while the ball is controlled
by sound lower limb, with a ball held by hands for thoracic and scapular stability,
left hemiplegia
is kept optimum to avoid hypertonicity. If the patient is unable to move the

limb actively throughout the range of motion, ‘placing’ is done by the therapist
and patient is asked to hold the limb in that position as far as possible. Note
the size of the ball in above activities. Moving the upper limbs in various
directions will aid in training multiple tasks where all four limbs and trunk
participate either as movers or stabilizers.
C H A P T E R
11
Activities in Sitting
INTRODUCTION
As soon as the general condition of the patient allows, progression from position
of lying to sitting is begun. From supine-lying, patient is taken to side-lying
on either side. With the support of upper limbs, and taking both lower limbs
near the edge of the couch with hip and knee flexed, simultaneous effort is
made to raise the body up as well as taking the lower limbs down. Activation
of synergistic patterns is prevented by assisting the patient wherever needed
and reflex inhibiting patterns like clasping the hands are used along with the
flexion of head and neck, trunk, hips and knees to counteract extensor thrust
activity.
The usual progression of activities would be:
TRAINING OF LYING TO SITTING USING TRUNK

The Figure 11.1 shows the method which is prerequisite to sitting. The patient
assumes the crook lying position. By flexing hip and knee further and by
flexing the trunk, both the knees are brought near abdomen by contraction
Activities in Sitting 201
FIGURE 11.1: Preventing extensor thrust, FIGURE 11.2: Rocking back and forth
left hemiplegia
of abdominal muscles. The patient is assisted to hold both the lower limbs
at the knee by both the upper limbs which are clasped around. A gentle rocking
of the trunk in flexion is done so that patient assumes a posture as shown
in Figure 11.2. Gentle rocking back and forth can be performed to practice
this activity. This is a total flexion pattern activity.
The therapist stabilizes both lower
limbs of patient at thigh level. By
holding both upper limbs, the patient
is instructed to actively flex head and
neck and trunk. The direction of the
movement is controlled by the therapist,
which may be flexion of the trunk or
flexion with rotation on the side on
which the therapist stands. This activity
strengthens trunk flexor and oblique
FIGURE 11.3: Abdominal activation, sup-
muscles. As the patient progresses, he ported, left hemiplegia
actively stabilizes lower limbs and,
assistance from the therapist in flexing the trunk also reduces. The upper limbs
are held as shown in the Figure 11.3, for ensuring flexion of thoracic spine
also. Care must be taken not to pull hemiplegic shoulder. Eccentric contractions
can be trained by controlling the movement by the patient while returning to
supine position.
SITTING FROM SIDE-LYING

In addition to promotion of early weight-bearing on the hemiplegic shoulder and
hip, this posture also elongates the lateral trunk flexors, which may be spastic.
Consider Figure 11.4. The patient can then be assisted in moving the legs over
the edge of the bed and pushing up to full sitting position using both arms.
The lower extremity can assist in rolling

by pushing off from flexed and adducted,
hook-lying position. This encourages an
important advanced limb pattern needed for
gait- hip extension with knee flexion and
also facilitates early weight-bearing in the
supine position. An alternate method
involves using a proprioceptive
neuromuscular facilitation (PNF) chop
pattern, which also encourages upper trunk
rotation and flexion with upper extremity
diagonal movement. The patient can be
FIGURE 11.4: Lying to sitting with
taught to use the leg to assist in rolling forearm support, left hemiplegia
by pulling the hip and knee up and across
the body in a flexion pattern (flexion, adduction, external rotation).
SITTING IN THE BED

Sitting in the bed for meals is not desirable, but may be necessary to fit in
with staffing and ward routine. The half-lying position should never be used,
as there is increased flexion of the trunk with extension in the legs and greater
risk of pressure sores. The patient should be as upright as possible with the
head and trunk in line and his weight evenly distributed on both buttocks. The
affected arm is protracted at the shoulder; both hands are clasped together and
placed forward on a bed-table. The legs are straight, not laterally rotated.
MOVING SIDEWAYS IN SITTING

In sitting, the therapist can aid the patient
in initially maintaining the posture by
ensuring proper pelvic alignment
(particularly pelvic anteroposterior
alignment, so that the patient’s foot is flat
on the support surface) and by having the
patient use extended arms for support. It
is important to use the affected arm for
support rather than leave it hanging. Gentle
resistance can be applied to assist in holding,
using techniques of alternating isometrics FIGURE 11.5: Shifting sideways in
rhythmic stabilization (Figure 11.5). Gentle sitting, assisted, left hemiplegia
rocking movements should incorporate moving forward, backward, side-to-

side, and in rotatory directions. Transferring sideways on both the sides initially
with assistance helps the patient to become mobile early in the process of
rehabilitation. Shifting sideways can be done in two ways, i.e. with lower
limbs grounded on the floor or without the assistance of the lower limb using
lots of trunk activities and lifting both the buttocks up alternatively with the
help of upper limbs. “Gluteal walking” sideways without the use of the upper
limbs can be used as a progression to this activity.
TRANSFER ACTIVITIES
Lying on the bed is restricted to few hours in a day even when the patient
is in the hospital. As soon as the general condition of the patient allows,
the patient is shifted to a chair. Sitting in a chair is a functional position
and apart from training variety of muscles and patterns of activities, it is
moral boosting for the patient. Visual scanning of the environment becomes
easy as the head is held upright. Overall perception of the patient also improves.
Much damage can be done to the patient’s shoulder as well as to the nurse’s
or therapist’s back during transferring the patient from bed to a chair, if this
maneuver is performed incorrectly. It can also be a very frightening time for
the patient, if he is suddenly transferred without any explanation or chance
to move himself. The following is an easy, safe, therapeutic way of transferring
a patient from bed to chair. The chair is placed in position on the affected
side and the patient is rolled or assisted on to his affected side. The helper
places one hand under the patient’s affected shoulder, swings his legs over
the edge of bed with her other hand, and brings the patient to the sitting
position (Figure 11.6). During this phase, elongation of the trunk occurs, and
if a pause is needed to rearrange clothes, etc., the patient can be propped
on the affected elbow and take weight throughout it. The patient, with his
A B C
FIGURES 11.6A to C: Sequential lying to sitting, left hemiplegia
A B
FIGURES 11.7A and B: Transferring from one sitting place to another, assisted,
left hemiplegia
hands clasped together in front of him, is helped to move to the edge of

the bed. He transfers his weight over to one side and then to the other and
moves the opposite hip forward each time as if he was walking on his buttocks.
The assistant’s arms are placed under the patient’s shoulders with her hands
over the scapulae while her leg wedges the patient’s feet and knees. The
patient’s arms are placed round the helper’s waists or on her shoulders, but
he must not grip his hands together. The patient is forward and he is brought
to standing by pressure forward and down on the shoulders, so that his weight
goes equally through both legs. No attempt is made to lift him up at all.
The assistant’s weight counterbalance the patient’s, and with shoulder and
knees fixed, he is pivoted round to sit on the chair (Figures 11.7A and B).
Transferring in such a way emphasizes the hemiplegics side and encourages
weight-bearing and weight transference to that side.
UPPER EXTREMITY CONTROL

Initial mobility of upper extremity can be achieved by focusing first on scapular
motions. Since the typical spastic pattern is one of retraction and fixation,
protraction with external rotation should be emphasized. This is typically
performed in sitting position as shown in Figures 11.8A and B.
The arm is mobilized forward and the patient is asked to hold this position.
If holding is successful, then eccentric and reciprocal movements are attempted.
Once initial control is achieved, the posture can be altered to a more challenging
one (e.g. active against gravity) and more active control of shoulder and elbow
components can be added through an increasing range. The patient should
be taught to mobilize the affected arm using hands clasped together (prayer
position). The therapist mobilizes the scapula in sitting position as shown
in Figures 11.8A and B, by keeping the upper limb cardled and fully supported.
A B
FIGURES 11.8A and B: Scapular retraction and protraction in sitting. Mobilization
and resisted workout in same grip, right hemiplegia
After this guided mobility, the patient is asked

to carry out this activity actively along with
reaching out.
Movements that should be stressed include
hand to mouth and hand to opposite shoulder,
since these have important functional
implications in feeding and dressing. Elbow
extension movements combined with shoulder
abduction or flexion should also be stressed
to counteract the effects of the dominant
flexion synergy. The quadruped posture
provides the greatest challenge for upper
extremity weight-bearing but may be too
FIGURE 11.9: Bilateral upper
difficult for some hemiplegia patients. An limbs held in clasped position and
alternate posture would be sitting, weight- affected side is kept supinated in
bearing on an extended arm on a stool in rip, left hemiplegia
front, as shown in Figure 11.9 or modified
plantigrade. Control should progress form initial holding in the posture to
controlled mobility using rocking movements.
CONTROL OF QUADRICEPS IN LONG SITTING

This activity is used to gain control of extensors of knee i.e., quadriceps in
sitting position. The patient assumes long sitting position as shown in Figures
11.10A and B. The affected lower limb is flexed at the knee about 15 to
20 degrees. The therapist stabilizes patient’s foot in dorsiflexion by his thigh
as shown. The patient is instructed to carry out knee extension gradually and
with control. The patient continuously watches the moving patella. The patient
A B
FIGURES 11.10A and B: Controlled knee extension in long sitting with foot stabilized,
left hemiplegia
may put his hand on quadriceps muscle for added proprioception. This activity
also trains gastrocnemius as well as soleus to some extent. As per the synergistic
pattern, it may be thought that planter flexors of ankle may not need attention
as they are already spastic. But in the contrary, the spastic plantar flexors
have no or little active control in sitting
and standing, which is required for
getting up and walking.
The patient is assisted to come into
long sitting position with affected knee
kept extended or slightly flexed. The
patient keeps both upper limbs on legs,
respectively and while flexing the back,
they are slided onto the legs. Note the
contraction of back flexor muscles as
the extensor muscles of back gradually FIGURE 11.11: Counteracting extensor
thrust of back in long sitting, left hemiplegia
relax in Figure 11.11. Lateral move-
ment of the trunk on either side by
keeping both upper limbs together on
the couch can also be practiced.
INHIBITION OF
EXTENSOR THRUST
The patient’s affected leg is crossed
over the sound one and is held in full
flexion and lateral rotation with the foot
and toes in full dorsiflexion, until it
will stay in position on its own (Figure FIGURE 11.12: Crossover of affected
leg to counteract extensor thrust of
11.2). Maintain inhibition at the foot
lower limb, left hemiplegia
and ask the patient to uncross his leg and lower it, making it feel light and
to raise it once more across the other leg.
To prepare for walking, teach the patient to move the legs without moving
the trunk, one leg at a time, asking to make it feel light by taking the weight
himself. They must maintain control while the leg is lowered onto the bed.
The patient is asked to keep his trunk still and not to lean back throughout
the activity.
WEIGHT SHIFTS IN HIGH SITTING

As the patient is propped up in high sitting position, assessment of weight-
bearing on both the ischial spine is checked for. For the ease of viewing
lateral folds of trunk, slight amount of neck flexion may be done. Figure
11.13 shows increased lateral folds on left side which is affected. The same
position can be used for correction in the posture and for training forward
flexion of the trunk.
Note the transition from back flexion in Figure 11.13 to back extension
in Figure 11.14. Slump and straightening of back is a good postural exercise
in making the patient understand pelvic tilts. Figures 11.15 and 11.16 show
the training of anterior and posterior pelvic tilt in sitting position.
FIGURE 11.13: Assessment of posture FIGURE 11.14: Back extension in sitting

in sitting for equal weight-bearing, left from flexion
hemiplegia
Anterior pelvic tilt associated with increase in lumbar lordosis as pointed

out in the Figure 11.15.
Posterior pelvic tilt is associated with obliteration of lumbar lordosis and
contraction of abdominal muscles (Figure 11.6). These exercises are taught
to the patient to carry out several times in a day.
FIGURE 11.15: Anterior pelvic tilt in FIGURE 11.16: Posterior pelvic tilt in
sitting sitting
SIMULTANEOUS ACTIVATION OF
UPPER LIMB AND TRUNK
After the practice of tilts, rotation of the trunk is started. As shown in Figure
11.17, the affected upper limb is held in adduction, flexion and few degrees
of internal rotation at shoulder with flexion of elbow, so that the hand rests
on opposite clavicular region. The sound arm cradles the affected arm so
that it does not drop off. Rotation of trunk in few degrees of flexion is gained
by instructing the patient to take the tip of elbow (olecranon) towards downwards
and to the left or right. Note the shifting of the weight on the affected side
ischial tuberosity.
Gradually, the cradling from the sound arm is reduced and it is kept free
to move actively in the direction of the rotation of the trunk.
Practice of abdominal activity along with stabilization of thorax in sitting
position is carried out by moving the sound upper limb while the affected
upper limb is kept on the right clavicular region as shown in Figure 11.18.
Note the flexion of the trunk which is gained by posterior pelvic tilt. In the
initial stages, this activity is of particular importance in gaining dynamic posture
control on sitting position. The sound upper limb position aids in increasing
the leverage.
Patient is instructed to move the affected (left in this case) elbow towards
opposite knee while the sound upper limb is maintained as shown in Figure
11.19. Note the movement of trunk in flexion and rotation. Also note that
the patient is constantly aware about the direction of the motion.
The sequence of the movement shown in Figures 11.20A and B is used
in gaining primary motor control of upper limb in sitting position. As seen
in the previous activities where the affected upper limb was either cradled
FIGURE 11.17: Rotation of trunk with the FIGURE 11.18: Active placing of sound
upper limb in RIP, left hemiplegia upper limb, while affected limb is stabilized,
left hemiplegia
FIGURE 11.19: Placing with added

flexion-rotation of the trunk to the right,
left hemiplegia
A B
FIGURES 11.20A and B: Active movements of left upper limb and placing it back,
left hemiplegia
by the sound limb or was supported by therapist, is now gradually left on

its own. Patient uses active effort in keeping the upper limb in the position.
The hand is lifted up from resting position by contraction of external rotation
of shoulder and is kept back slowly. The therapist may have to assist at the
elbow to prevent exaggerated abduction of the shoulder. Note the position

of the right hand of the therapist which is stabilizing the scapula as shown
in Figure 11.20B. This activity trains the movement of scapula protraction,
shoulder adduction with external rotation and this position is also a precursor
to controlled elbow flexion with supination of forearm.
WEIGHT-BEARING THROUGH
UPPER EXTREMITIES
The patient is instructed to keep both upper limbs at one side with weight-
bearing on both palms as shown in Figure 11.21. The therapist assists in
keeping affected palm on the couch by extension and abduction of fingers
and thumb and extension of wrists. Affected elbow is not allowed to drop
in hyperextension i.e., in a locked position. Controlled flexion of elbow in
the weight-bearing position is done and patient comes back to the starting
position once again. This close chain activity is carried out mainly by the
contraction of triceps and is useful in counteracting the flexor synergy. Rotational
component of the trunk will
physiologically reduce the flexor tone.
Figures 11.22A and B show
dynamic activity on both the sides as
explained above.
Figure 11.23 shows weight-bearing
on affected limb sideways. Here, note
the weight shifted on affected ischial
tuberosity. As the patient shifts the
weight towards affected side, the trunk
on that side elongates. This is a true FIGURE 11.21: Weight-bearing through
method of weight-bearing; if done upper limbs sideways, left hemiplegia
A B
FIGURES 11.22A and B: While weight-bearing sideways, gradually flexing and
extending elbows
FIGURE 11.23: Conventional weight- FIGURE 11.24: Incorrect method of

bearing through affected upper limb, left weight-bearing
hemiplegia
incorrectly, the trunk on affected side will flex which will result into increased
stiffness of trunk and decreased weight-bearing on upper limb. Figure 11.24
shows the incorrect method of weight-bearing.
UPPER EXTREMITY PLACING

Active motor control activities of the upper limb can be started once dynamic
balance reactions and weight-bearing improves. There are many methods by
which this goal can be achieved. Activities which promote active control of
the muscles that are antagonists to the synergistic patterns, are used either
individually in initial stages or as combined movements as the patient progresses.
The method of ‘placing’ is used in which the therapist places the upper limb
of the patient in a desired pattern of activity and the patient is instructed to
hold that position. Figure 11.25 shows placing in following pattern: shoulder
flexion, abduction, external rotation, elbow partial flexion, forearm supination,
wrist in neutral extension, fingers extended and thumb extended and abducted.
Assistance may be given at few levels, as shown in Figure 11.25, assistance
is given to keep the arm externally
rotated and forearm supinated (by
holding the thumb).
Training of shoulder adduction with
external rotation along with the upper
limb in reflex inhibiting posture can
be achieved by pressing a moderately
thick pillow under the axilla on both
the sides. The therapist holds the
affected upper limb in the following FIGURE 11.25: Active-assisted placing
position: shoulder externally rotated, of affected upper extremity, left hemi-
elbow extended, forearm supinated, plegia
FIGURE 11.26: Pillow compressions to train shoulder adduction with

external rotation, bilateral pattern, left hemiplegia
wrist extended, fingers extended and thumb extended and abducted, as shown
in Figure 11.26. Sound upper limb may be held actively in this position or
the therapist may guide the movement. The patient is then asked to compress
the pillows with their arms. This activity is useful for training shoulder adduction
with external rotation while forearm is supinated. This activity has functional
implication on the movements of upper limb in front of the body, e.g. eating,
wiping the face, etc.
DYNAMIC BALANCE REACTIONS

Moving more dynamically on the couch readies the patient to face challenges
in the environment at functional level. Transferring the weight completely
to the affected ischial tuberosity can be achieved by assisting the patient’s
affected upper limb in abduction of 90 degrees at shoulder and shifting towards
affected side. Note the compensatory hip internal rotation on the sound side
where the affected side hip externally rotates in Figure 11.27. Also note the
dorsiflexion and eversion of the foot on normal side. The same activity can
be performed by taking weight on sound side for gaining benefit of compensatory
activity on the affected side throughout the kinematic chain.
The above mentioned exercise can be progressed by decreasing the assistance
and allowing the patient to move the affected limb more actively. When the
patient is moving actively, the sound upper limb counteracts the force of
movements towards gravity by taking a center of gravity within the base of
support. Please note the movement of trunk side flexion towards sound side
(right side in this case) in Figure 11.28.
In the patient where weight shift towards affected side is difficult due to
any reason, the technique shown above is implemented. The therapist sits
on the affected side of the patient and holds the rim of the pelvis as shown
in Figure 11.29A with both hands, one at back, another in front. The therapist
FIGURE 11.27: Dynamic balance reac- FIGURE 11.28: Moving more actively
tions sideways in sitting, left hemiplegia and dynamically
A B
FIGURES 11.29A and B: Assisted and active lateral pelvic tilts, left hemiplegia
elongates the trunk on that side and inhibits any flexion in the arm. The
patient’s good leg is then free to be raised in the air. The body-weight is
shifted over the sound side, and the head is placed in position if it is not
right automatically. Side flexion of his trunk on the affected side is facilitated
by giving pressure at the waist with one hand and encouraging lifting the
buttock clear of the bed. The movement is repeated in a rhythmic manner
until automatic head and trunk righting occurs to both sides.
The therapist then instructs the patient to lift the sound ischial tuberosity
off the couch while he pulls the pelvis up and towards himself. Note the
elongation of the trunk on the affected side while the trunk side flexes on
the sound side in Figure 11.29B.
The therapist then decreases the assistance and can just guide by holding
the affected upper limb in scaption as shown in Figure 11.30A.
Facilitate increased balance reactions of the head, trunk and upper limbs
by lifting both legs together and rotating them to either side. Alter speed
and position to obtain the required reactions in the rest of the body. The
affected arm should assist balance in a similar way to the sound arm and
not pull into flexion (Figure 11.30B). The patient is instructed to hold this
shifted position for longer duration for progression. If the effort on the part
of the patient increases, hypertonia may result on the affected side. To counteract
A B
FIGURES 11.30A and B: (A) Affected side weight-bearing on ischial spine, left
hemiplegia, and (B) Dynamic balance reaction with guiding lower limbs, left hemiplegia
this, either the effort on the part of the patient is reduced or assistance by
the therapist is increased.
MOVING LOWER LIMB

Active movements of lower limb
associated with the activation of
abdominal muscles has an added
advantage of counteracting synergistic
patterns throughout the lower half of the
body whereas upper body adapts
automatically. A unilateral flexion of
affected hip can be practiced while the
pelvis is posteriorly tilted. This movement
elicits activity of tibialis anterior and toe FIGURE 11.31: Moving lower extremity
flexors which can be prevented by keeping in flexion along with trunk flexion
activation, left hemiplegia
the hip adducted and internally rotated.
Patient is instructed to take the affected knee towards opposite side chest. Active
relaxation of tibialis anterior and other foot muscles is practiced by the patient
along with the hip movements. Progression can be made by moving both the
upper limbs and holding this position as shown in Figure 11.32. Note the contraction
of lower abdominals in Figure 11.31 and also note the contraction of upper
and lower abdominals both in Figure 11.32. Patient’s attention is always focused
on the quality of the moving lower limb.
Similar activity can be performed by the sound limb also. This gives an added
advantage of weight shift towards affected side. Thus, active lower limb movements
on both the sides encourage obliques and transversus abdominis (Figure 11.33).
FIGURE 11.32: Lower limb flexion along FIGURE 11.33: Flexion of sound side
with movements of upper extremities, left lower extremity, left hemiplegia
hemiplegia
WEIGHT SHIFT ON ELBOWS, SIDEWAYS

The patient takes weight on elbow on affected side with trunk on that side
elongated. Figure 11.34A shows incorrect method of weight-bearing in which
the trunk side flexes on the affected side. This can be prevented by giving
the assistance to the lateral pelvic tilt and side flexing the trunk towards sound
side (Figure 11.34B). The progression of the activity can be done by asking
the patient to rock forwards and backwards, axis being at elbow.
A B
FIGURES 11.34A and B: Weight-bearing on affected elbow: (A) incorrect method
and (B) correct method
SITTING IN THE CHAIR

A better sitting posture can be obtained in an upright chair. The chair should
be of sufficient height to allow the patient’s hips, knees and ankles to be
approximately at right angles when he sits well back in the chair. His head
and trunk are in line with the body-weight evenly distributed over both buttocks.
His hands are clasped and placed well forward on a table in front of him
(Figure 11.35).
A B
FIGURES 11.35A and B: Sitting on a chair with legs FIGURE 11.36: Flexion of
crossed, left hemiplegia trunk while sitting on chair
with clasped hands
With the hands clasped in front, and elbows extended, the patient can practice
reaching out to either side, forward and down to the feet (Figure 11.36).
WEIGHT TRANSFERENCE ON AFFECTED

UPPER LIMB WITH REACHOUTS
The hand is placed flat on the bed or plinth and with one hand under the
axilla and the other supporting the elbow (Figure 11.37A). The therapist draws
the patient toward the elongating trunk at the same time. Weight transferring
on the affected upper limb can be enhanced by reaching out by the unaffected
upper limb towards the affected side as shown in Figure 11.37B. The therapist
may support the elbow of the patient to prevent exaggerated flexion or extension.
A B
FIGURES 11.37A and B: Weight-bearing on affected side while reaching out with
sound side, left hemiplegia
The patient may cross over the other to completely transfer the weight
on the affected side ischial tuberosity. Reaching out can also be carried out
with affected upper limb in various directions that train optimum weight shifts.
Note Figures 11.38A and B, where during reachouts, the affected side trunk
elongates along with complete weight-bearing on affected side ischial tuberosity.
A B
FIGURES 11.38A and B: Reachouts with affected upper extremity with legs crossed,
left hemiplegia
MOVING IN SITTING POSITION

While one leg remaining flexed, make the patient transfer the weight on to
the hip of the underneath leg and lift the other buttock off the bed. Facilitate
flexion of the trunk with pressure at the waist (Figure 11.39). Repeat the
same activity to both sides. The patient must be moved in sitting without
A B
FIGURES 11.39A and B: Gluteal walking, right hemiplegia
using the hand. The patient is taught to shuffle

or walk on the buttocks forwards and backwards
and later sideways. Help is given by placing
one hand under each hip or thigh and then
rock and move from side to side.
WEIGHT TRANSFERENCE
THROUGH THE ARMS BEHIND
Both arms are taken carefully behind the patient
with the hands being supported on the
therapist’s hands. Extension is facilitated by
using a sharp push-pull action up through the
arms until they support his weight (Figure FIGURE 11.40: Weight-bearing
11.40). Progress is made by shifting the weight behind, right hemiplegia
from one side to the other without bending
the elbows.
NECK STRETCHING
All the movements of neck need to be stretched and strengthened in sitting
position as it is a functional position. Stretching of sternocleidomastoid on
both the sides is best done in sitting position with the patient on the chair
or a stool and therapist standing behind (Figure 11.41). Stretching of upper
trapezius is also vital. Neck posture due to insufficient sternomastoid is often
distorted. There may be a difference in strength of clavicular and sternal fibers.
Note Figure 11.42.
In Figure 11.42 of patient with right side hemiparesis, note the difference
in contraction in clavicular and sternal fibers of sternocleidomastoid. Right
side sternal fibers are not activated at rest but they participate, though weakly,
A B
FIGURES 11.41A and B: Neck stretching, right hemiplegia

FIGURE 11.42: Asymmetrical activation FIGURE 11.43: Asymmetrical activation

of sternal and clavicular fibers of sterno- of sternal and clavicular fibers of
cleidomastoid muscle, right hemiplegia, sternocleidomastoid muscle, right
at rest hemiplegia, during activity of upper
extremities
when attempting shoulder elevation as seen in Figure 11.43. Note the deviation
of the chin towards sound side, i.e. rotation of neck towards sound side and
side flexion towards affected side. Also note the exaggerated contraction of
upper trapezius on affected side.
Training of hand function should emphasize forearm, wrist, and finger
movements independent of shoulder and elbow motions. Excessive shoulder
adduction, elbow flexion, pronation, and finger flexion are the typical spastic
patterns that must be counteracted. Voluntary release is generally much more
difficult to achieve than voluntary grasp, and inhibitory techniques may be
necessary before extension movements are successful. Prehension patterns should
be practiced and manipulation of common objects attempted. The therapist
needs to observe these movements carefully and to assist the patient in eliminating
those aspects of performance that interfere with effective control.
ACTIVATION OF WRIST EXTENSORS

Activation of wrist extension is best done
in sitting position where the patient is
watching the movement throughout.
Brushing is done at the start of the
treatment as it has a latency period for
its effect on contraction of the muscles.
Optimum speed for brushing is selected
and is carried out at the extensor surface
of the forearm upto the dorsal aspect of
distal end of the fingers, as shown in FIGURE 11.44: Brushing for long exten-
Figure 11.44. Other activities then follow. sors of wrist and fingers, left hemiplegia
A scrubber can be used which provides a different texture for elicitation

of the extensor muscles. Immediately after a quick stroke, patient is asked
for active wrist extension. This technique has proved to be highly effective
and hence, can be used frequently. As with any sensory activation, number
of repetitions is kept to 4–5 strokes to avoid sensory adaptation.
A B
FIGURES 11.45A and B: Scrubber for facilitation of wrist and fingers extension,
left hemiplegia
Figures 11.45A and B show the activation of long extensors of forearm

and reciprocal relaxation of the flexor muscles of wrist and fingers immediately
after using a brush and a scrubber. This reciprocal relaxation can be used
in favor of wrist and fingers extension. Patient is asked to keep attention
on raising tips of fingers rather than wrist extension as it can be done by
flexion of fingers as in tenodesis; which is an unwanted action as it increases
tone of flexor digitorum superficialis and profundus muscles.
SHOULDER ACTIVITIES
Activities of shoulder in sitting position require the shoulder to move in flexion
without an exaggerated response from abductor muscles. Figure 11.46A shows
an active attempt to lift left hemiplegic upper limb. Due to synergistic activities
A B
FIGURES 11.46A and B: Synergistic patterns of left upper extremity on active
effort, left hemiplegia
the upper limb goes in the following pattern: shoulder abduction, internal
rotation with elbow flexion. The more the patient puts his efforts in raising
the upper limb, the more synergistic it gets. To prevent this, assistance from
the therapist in guiding the movement in desired direction is mandatory.
Many a times for patient with hemiplegia, even the slightest amount of
movement is encouraging, even if it may be in synergistic pattern. Thus, the
therapist may not always discourage the patient from carrying out that activity
but teaches him a proper method, e.g. activities with clasped hands or using
minimal assistance as in guiding the motion.
PREPARATION FOR HAND ACTIVITY

Rehabilitation of upper limb functions post hemiplegia is one of the most
challenging aspects for the treating therapist. Adequate head and neck control,
scapular stability and mobility, thoracic and lumbar stability, shoulder external
rotation and forearm supination are vital in gaining control over wrist and
fingers. Nevertheless, activation of all the aforesaid parts is done in unison.
Many activities overlap each other for one final aim of gaining motor control
in upper limb. These activities help in making the patient independent.
With the patient sitting in chair, the therapist stands on the affected side
with one hand controlling the scapula and the other hand resisting abduction
of affected shoulder in scaption position. Isometric contraction in this angle
is helpful in eliciting long extensors of forearm. Patient is asked to extend
wrist and fingers as best as they can, while the therapist maintains the resistance.
Overhead shoulder flexion with elbow extension also elicits contraction of wrist
and fingers extension. As patient tries to extend the wrist and fingers, a brisk
stroke by the therapist is given for facilitation. After releasing the resistance,
the patient is asked to extend wrist and fingers while the therapist holds the
affected upper limb in front of the patient’s body as shown in Figure 11.47.
A B
FIGURES 11.47A and B: (A) Active wrist and fingers extension in sitting, left hemiplegia
and (B) active supination of forearm with upper extremity in front, left hemiplegia
Patient is then asked to supinate the forearm while the therapist holds the
upper limb in external rotation from the shoulder. Patient also concentrates
on keeping the palm open.
If the patient is unable to extend the fingers, the grip which is shown
in Figure 11.48A is used. Here, the therapist is holding the patient’s wrist
so that the force of muscular contraction is concentrated on extending the
fingers. Therapist may have to flex the wrist initially to use the length tension
relationship of long extensors. Similar grip is used for supination of forearm.
This movement can be resisted to gain abduction and extension of thumb.
Figure 11.48B shows good extension of fingers actively with the therapist
holding patient’s forearm in supination. Note the uncontrolled fanning of all
the fingers. Patient is instructed to keep fingers in adduction. Note Figure
11.49A given below in which the patient attempts although incompletely to
adduct the fingers.
Figure 11.49B shows the use of a rubber band to control fanning of fingers.
The band can also be used in extending the fingers as the band would help
A B
FIGURES 11.48A and B: (A) Grip for opening of fingers and extension abduction
of thumb, left hemiplegia and (B) grip for assisted supination for fingers extension,
left hemiplegia
A B
FIGURES 11.49A and B: (A) Active adduction-extension of fingers, left hemiplegia
and (B) use of a rubber band in assisting fingers adduction
in uniform movements of all fingers. The band can also be used for giving
resistance as and when required.
FOREARM SUPINATION AND ELBOW FLEXION

Patient performs activities of elbow,
wrist and fingers with the upper limb
in front supported adequately by a firm
pillow. Figure 11.50 shows active
supination of forearm. For the patient
who is unable to carry out the
movements themselves, assistance (self
or by therapist) can be given in the same
position. Resistance to supination
movement at later stages can be carried
out using the same position. FIGURE 11.50: Active supination
supported by a pillow, left hemiplegia
Once the supination of forearm is
achieved, the elbow can be selectively flexed keeping the forearm supinated.
This movement is useful in functional activities like wiping the face, eating
etc. shoulder should be kept in adduction and external rotation to avoid
unnecessary and exaggerated movement of the arm. If this position is not
achieved and maintained actively, the therapist may assist to keep the arm
stabilized by holding lower end of humerus against the chest wall.
Figures 11.51A and B show the abduction and external rotation of shoulder
while the patient is attempting hand to mouth activity. The patient may be
asked to stabilize the affected arm with sound arm at elbow as shown in
Figure 11.52.
A B
FIGURES 11.51A and B: (A) Hand-to-mouth side view and (B) hand-to-mouth front
view, note the position of arm, left hemiplegia
FIGURE 11.52: Self stabilization of arm FIGURE 11.53: Active-assisted shoulder

while performing hand to mouth, left external rotation with elbow flexion, left
hemiplegia hemiplegia
FIGURE 11.54: Active external rotation FIGURE 11.55: Active shoulder external
with minimal assistance rotation
SHOULDER EXTERNAL ROTATION ACTIVITIES

Active external rotation of affected shoulder with adduction along with elbow
in flexion in sitting position is practiced as shown in Figure 11.53. The therapist
may assist the patient in keeping the arm close to chest wall so that the effort
of the patient is concentrated on external rotation of the shoulder only. Later
on, this assistance can be taken off and patient can selectively perform the
activity of shoulder external rotation with adduction.
Figure 11.54 shows active external rotation movement of shoulder while
elbow is flexed and forearm supinated. Note the assistance given from behind
the patient. Gradually, assistance is reduced and patient is asked to maintain
the position. Note the Figure 11.55.
USE OF ELASTIC BAND IN APPLYING RESISTANCE

As soon as possible, resistance to all possible movements can be given by
a use of elastic band. Initially, very light resistance can be given. Though
FIGURE 11.56: Resisted external rotation FIGURE 11.57: End position of external
using elastic band rotation of shoulder
manual resistance given by the therapist

is the best form of resistance, the use
of elastic band gives the liberty of using
resistance by patient at home too. Note
the stabilizer band attached to patient’s
affected arm in Figure 11.56. Patient
attempts pulling the elastic band in
direction of external rotation of
shoulder, while the assistant holds the
elastic band firmly in opposite direction
to the direction of motion at 90 degrees.
Figure 11.57 shows the end position
of the activity.
Similarly, movements of elbow FIGURE 11.58: Resisted elbow flexion
flexion and extension can also be using elastic band, left hemiplegia
resisted using the elastic band. If
hypertonia results post activity, caution is advised. See Figure 11.58.
USE OF A BALL IN APPLYING RESISTANCE

A slightly deflated ball can be very useful in applying resistance to desired
movements. Many purposeful movement combinations and activities and
can be designed for individual use. Some of the activities are described
here.
Figure 11.59 shows the use of ball

in resisted activity of shoulder
adduction while the therapist maintains
the arm in external rotation and
forearm supinated. The patient is asked
to press the ball against the lateral chest
wall and hold that position for as long
as he can.
Ball can be pressed between both
hands which will also improve
proprioception along with strength of
muscles. Care must be taken not to
allow synergistic activity to take over.
Adequate guiding may be required at
some instance for maintaining the
quality of movement.
By pressing the ball between the FIGURE 11.59: Resisted shoulder
hands and with pressure over the root adduction using a ball, left hemiplegia
of the affected palm (Figure 11.60),
there is an elicitation of wrist and fingers
extension. Figure 11.61 shows the
extension of the fingers with pressing
the ball. Note the assistance given by
the therapist at the level of the wrist to
guide the movement in a right direction.
Patient’s affected side is left.
Ball can be pressed in different
directions for gaining various results.
The hands may completely mold the
FIGURE 11.60: Ball pressing with both
ball for hand functions to improve. hands, left hemiplegia
Assistance from the therapist in mould-
ing can be given initially till the patient
achieves it himself (Figure 11.62).
Figures 11.63A and B show a
different position in bearing the weight
on root of the palm with use of a ball.
Here, the patient uses serratus anterior
with elbow in few degrees of flexion
in applying the pressure while the
FIGURE 11.61: Assisted ball pressing
therapist directs the force in a proper with the root of palm for facilitation of
way. wrist extension, left hemiplegia
FIGURE 11.62: Ball pressing with affected forearm in supination, left hemiplegia
A B
FIGURES 11.63A and B: Ball pressing in front, left hemiplegia
USE OF STRETCH REFLEX

Use of stretch reflex in finger and wrist extension can be used as shown
in Figures 11.64A and B. A quick movement of flexion of wrist and fingers
is done and the patient is asked to extend them immediately. The same grip,
as shown in Figures 11.64A and B, is used to resist the movement of wrist
and fingers extension.
A B
FIGURES 11.64A and B: Stretch reflex for fingers extension, left hemiplegia
USE OF BILATERAL UPPER LIMB ACTIVITIES

To train the affected upper limb, the use of sound limb is very useful because
all the movements of sound side can influence the affected side. Hence, the
training for the affected side is started by moving the sound limb first. The
patient registers this movement in the brain and then mirrors it to the affected
side. In this method, lot of visual and auditory cueing is used by the patient
as well as by the therapist. Patient is taken in sitting position with both the
upper limbs in front of the body and in line of the vision. Activities of forearm,
elbow, wrist and fingers can be readily done in this position. Figures 11.65A
and B show the sequence of forearm supination and pronation training. Guidance
by the therapist can be given, as and when required.
A B
FIGURES 11.65A and B: Bilateral symmetrical pattern of pronation and supination,
left hemiplegia
Bilaterally asymmetrical pattern of activities can be started when the patient

has mastered the symmetrical patterns. Figures 11.66A and B show the pattern
of pronation and supination, asymmetrical in both the forearms.
A B
FIGURES 11.66A and B: Bilateral asymmetrical pattern of pronation and supination
Note the sight abduction and internal rotation of affected left shoulder while
attempting pronation of forearm.
MOVING THE HAND

Modification and progression of the very famous ‘clasp hand’ activity is shown
in Figures 11.67A and B. Both the hands are kept in a ‘namaskar’ position
as shown in Figure 11.67A. This position reduces the flexor tone of the long
flexor muscles. After optimum reduction of the tone is achieved, wrist extension
with the fingers kept in extension, is practiced. A rubber band can be attached
to all the fingers to keep them together and aid in finger motion. See Figure
11.68.
A B
FIGURES 11.67A and B: Bilateral wrist and fingers FIGURE 11.68: Use of a rub-
extension, left hemiplegia ber band to prevent abduc-
tion of fingers, left hemiplegia
Extension and abduction of thumb is practiced in the position explained

above.
A B C
FIGURES 11.69A to C: Bilateral abduction and extension of thumb with fingers
flexed; note the use of rubber band for fingers, left hemiplegia
Note Figures 11.69A to C, in which the patient attempts bilateral extension

and abduction of thumb with the fingers held in flexion. The use of a rubber
band can be useful as explained before. Assistance from the sound thumb
can be done by the patient if active movements are inadequate in same position.
Use of brushing, icing, myofacial release and other techniques can be used
for activation of abductor pollicis longus and extensor pollicis longus and
brevis.
Practice of fingers extension and flexion can be performed after stabilizing
the wrist and forearm with sound hand as shown in Figures 11.70A and B.
A B
FIGURES 11.70A and B: Active extension of fingers with forearm supinated by
sound limb, left hemiplegia
By fixing lower end of radioulnar joint in supination, the patient attempts

flexion of fingers very gradually and gently. The patient opens up fingers
as far as possible, and the position is held as long as possible. Initially, assistance
from the therapist may be required in opening up the fingers. A conical-shaped
object can be placed in patient’s palm with the narrow portion held towards
the ulnar side and the broad portion towards the radial side. Use of the cone
is helpful in eliciting finger extension.
A B
FIGURES 11.71A and B: (A) Thumb to index finger; (B) thumb to middle finger
A B
FIGURES 11.72A and B: (A) Thumb to ring finger and (B) thumb to little finger
As shown in Figures 11.71 and 11.72, approximation of tip of the thumb

to tip of all the fingers is first practiced with assistance. As the dexterity
of the movement improves, assistance can be gradually decreased and active
movements are encouraged.
ACTIVITIES ON VESTIBULAR BALL

Anticipatory postural adjustments can be challenged by having the patient
perform voluntary movement that have a destabilizing effect. For example,
the therapist can utilize static-dynamic activities of PNF chopping or lifting
patterns or cone stacking activities. Dynamic surfaces like the wobble board,
foam wedge and vestibular ball can be used for the dynamic surface balance
training. Once initial control is achieved, the patient is ready to practice more
dynamic balance activities. The therapist should have the patient explore his
or her limits of stability (LOS) through low-frequency sway. Thus, the patient
learns how far in any one direction he or she can move, while typically
maintaining upright stability. Patients with hemiplegia typically demonstrate
reduced voluntary sway with more weight being directed on the sound side
than on the affected side. The therapist will, therefore, need to stress symmetrical
postures, as well as, activities that overcompensate, shifting the weight more
on to the affected extremities. Gentle perturbations can be used to displace
the patient’s center of mass (COM) and stimulate postural adjustments. The
therapists can also have the patient sit or stand on a movable support surface,
thereby stimulating adjustments through displacement of the base of support
(BOS). For example, a gymnastic ball or equilibrium board can be used. The
patient learns to actively control posture while the device is moved, or while
the patient actively moves the device.
A vestibular ball of optimum size is selected so that the patient’s hip and
knee flexed at around 90 degree and both the soles of feet touch the ground
comfortably. Ball is slightly deflated to increase the friction of the ball to
the surface and thus, ensuring a slightly larger base of support. A suitable
floor mat is used to prevent skidding. Preferably the patient should sit on
the ball facing a mirror for visual bio feedback. At first, the patient is made
to sit on the ball as a part of orientation program. Adequate support may
be required initially to decrease the fear of falling off the ball. Once the
fear is reduced, assessment of the balance can be done in a correct manner.
Usually, sitting steadily on the ball with equal weight-bearing on both the
sides requires assistance from the therapist. The therapist may kneel on either
side or behind the patient. Assisted weight shift in different directions can
be started once the patient stabilizes on the ball.
Figure 11.73 shows correct position of sitting

on the ball.
Figures 11.74A and B shows posterior
shifting of weight assisted by the therapist.
Figure 11.74A shows the therapist assisting from
behind. This position is easier for the patient
as he feels more secure. Figure 11.74B shows
the therapist holding the patient from distal end
of femur which can be used as a progression
of the activity stated before. In either of the
case, strong contraction of abdominal is required
to maintain the balance. To workout obliques
FIGURE 11.73: Orientation in
of abdominals, diagonal patterns of activity are sitting on a ball, left hemiplegia
used i.e, shifting of the weight posteriorly and
to the right or left and anteriorly in either directions. Note Figures 11.75A
and B.
FIGURES 11.74A and B:

(A) Posterior weight shifts
on ball, assistance from
behind left hemiplegia,
(B) posterior weight shifts
on ball, assistance from
A B front, left hemiplegia
FIGURES 11.75A and B:

(A) Diagonal weight shifts,
posteriorly and to the left,
(B) diagonal weight shifts,
posteriorly and to the right A B
As the patient gets used to these

positions, active movements in either
directions with the feet on the mat can
be started.
Figure 11.76 shows active shifting
on sound side. Patient’s affected side
is left.
All these activities can also be
resisted from pelvis by the therapist.
Initially, unidirectional movement can
be resisted, i.e., forward and backward
FIGURE 11.76: Lateral pelvic shifts on
shifting and lateral shifting to the right ball, left hemiplegia
and to the left. Resistance to the
diagonal movements can be used as a progression.
Figures 11.77A and B show the resisted workouts for forward and backward
shifting.
A B
FIGURES 11.77A and B: (A) Resisted forward shift, and (B) resisted backward shift
The patient is asked to clasp both the hands and bring them in front of
the body to stabilize the thorax (Figure 11.78A). Gradually, the patient is
asked to lift the sound leg up in the air as shown in Figure 11.78B and
maintain the balance. Then, affected leg is lifted up actively in a similar fashion
and balance is maintained as shown in Figure 11.78C.
As the patient achieves the maintenance of posture with single leg on the
ground, the leg can be crossed over on the other leg and reaching out can
be practiced in various directions to improve dynamic postural control and
overall proprioception (Figure 11.79).
Figures 11.80A and B show the affected lower limb (left) crossed over
on the sound lower limb. Once the posture is maintained, reaching out with
affected upper limb can be started in anti-synergistic postures.
A B C
FIGURES 11.78A to C: (A) Maintaining balance with clasp hands, (B) raising sound
limb up, left hemiplegia, and (C) raising affected limb up, left hemiplegia
A B
FIGURES 11.79A and B: (A) Reachouts with affected upper extremity, left hemiplegia,
and (B) balancing with legs crossed
A B C D
FIGURES 11.80A to D: (A and B) Affected leg crossed over sound leg, reach
outs with affected upper extremity, left hemiplegia and (C and D) sound leg crossed
over affected leg, reach outs with affected upper extremity, left hemiplegia
Figures 11.80C and D show crossing over of sound lower limb (right) on
the affected side. In either case, the reaching out can be done by both the
hands clasped together, if active control of the affected upper limb is insufficient
to complete the movement.
Sit-to-stand transitions should be practiced, with an emphasis on symmetrical

weight-bearing on both the lower limbs and controlled responses of the
hemiplegic side as shown in Figure 11.81. Trunk rotation can be increased
by having the patient stand up and shift the pelvis to one side or the other
before sitting down. Arms should be clasped and held straight ahead during
this activity. A vestibular ball can be used in variety of ways; the patient
can sit on the ball and carry out hand functions as shown in the Figure below.
Dynamic postural control can be maintained effectively, while the patient can
perform other functional tasks.
See Figure 11.82; here, the patient has put the affected right upper extremity
in reflex inhibiting posture supported by a table in front while sitting on a
ball. As a part of progression in balance training, the patient is taken in a
crossed leg position on a vestibular ball as shown in Figure 11.83.
FIGURE 11.81: Sitting to FIGURE 11.82: Affected FIGURE 11.83: Crossed

standing upper extremity held in leg sitting on a ball, sup-
reflex inhibiting posture ported, right hemiplegia
while sitting on a vestibular
ball, right hemiplegia
For sitting crossed leg on the ball, the patient is given adequate support
from behind and asked to relax upper limbs as much as possible. After this
position is maintained for sometime, gentle movements in forward and backward
directions are started. The therapist holds the patient’s pelvis and assists in
the movement while the patient maintains the upright position. Strong contraction
of trunk muscles is required to maintain the posture on the ball. Diagonal
patterns can later be added as shown in Figures 11.84A and B. Backward
and to the right, backwards and to the left, forwards and to the right and
forwards and to the left are the diagonal patterns which can be incorporated
in the list of activities. Note the reactions of both upper limbs in these Figures.
A B
FIGURES 11.84A and B: Diagonal patterns while sitting cross-legged on the ball,
right hemiplegia
Patient’s affected side is right and movements of both the upper limbs counteract
the movement of the trunk to maintain the center of gravity.
While sitting on the ball, affected side upper limb activities in PNF patterns
can be started as shown in the Figure given below. The pattern of flexion,
abduction and external rotation can be trained and later on can be resisted
as shown in Figures 11.85A to C and Figures 11.86A and B. Adequate guiding
from the therapist may be required at distal or proximal level to ensure quality
of the movements.
The pattern of extension, abduction and external rotation is shown in Figures
11.86A and B.
A B C
FIGURES 11.85A to C: PNF patterns on vestibular ball, flexion-abduction-ER, left
hemiplegia
A B
FIGURES 11.86A and B: Extension-abduction ER pattern, left hemiplegia
The patient can carry out ball catching and throwing activities while seated
on the ball which trains dynamic postural control and aids in dynamic postural
stabilization. Please note Figures 11.87A and B.
A B
FIGURES 11.87A and B: Ball catching while on vestibular ball, left sensory stroke
 Supine on ball
The patient can be taken supine on the ball with adequate support. The patient
is first made to sit on the ball and is asked to take steps forward one by
one gradually, while still maintaining contact with the ball till the patient’s
upper back rests on the ball as shown in Figure 11.88A. Adequate support
is required so as to prevent the patient sliding off the ball. The patient is
then asked to maintain the pelvic position in upward direction and assistance
may be given by the therapist if the patient is unable to hold this position.
For further workout of stabilizer of the thorax, both the upper limbs of the
patient are flexed up to 90 degrees from shoulder. Side to side movements
of the upper trunk can be carried out, while keeping the feet firmly on the
ground to strengthen the rotator of the trunk and training the advanced balance
reactions (Figure 11.88B). As a progression to this activity, one by one, lower
A B
FIGURES 11.88A and B: (A) Supine on a ball, raising the trunk, left hemiplegia
and (B) supine on a ball, raising the trunk, raising the upper limbs, left hemiplegia
A B
FIGURES 11.89A and B: (A) Unilateral bridging on sound limb while supine on
ball, right hemiplegia and (B) unilateral bridging on affected side while supine on
ball
limbs can be raised up in the air thus maintaining the entire weight only
on a single lower limb (Figure 11.89).
 Turning on Ball
Practicing quarter and full turns can be taught to a well-recovering patient
as shown in Figures 11.90A to D. The patient is helped to turn to either
side by using both the upper limbs as lever. While half turning, both the
feet are kept firmly on the ground. Weight is taken on the lateral aspect of
the trunk and the patient is asked to breathe in and out normally but slowly.
During the practice of three-fourth turns on right side, the patient flexes
his right lower limb as shown in the Figure 11.90D. The left lower limb
crosses over to the right side. Both the upper limbs can be clasped together
or can also be kept separate but in line as shown. Gradually, the patient pivots
the weight on the lateral aspect and then to the anterolateral aspect of the
right trunk. The patient can also be taken prone on the ball by extending
the above mentioned procedure till both the hands of the patient rest on the
mat. All these activities require enormous amount of skill and control for
A B
C D
FIGURES 11.90A to D: (A) Half turn to the sound side, left hemiplegia, (B) half
turn to the affected side, (C) three fourth turn to the sound side, (D) three fourth
turn to the affected side
the patient. Till then, the therapist supports the patient full and gradually decreases
the support as and when required. Increased effort and lack of dynamic balance
reactions increase muscle tone of the patient and hence, if any increase in
tone is noticed after completion of the exercises, these may be discontinued
or effort on the part of the patient is reduced by proper assistance by the
therapist.
 Prone on Ball
In the kneeling position with the ball in front, the patient places both the
upper limbs on the ball with elbow kept in extension (Figures 11.91A and
B). If due to spasticity, this position cannot be maintained individually, than
the patient can clasp hands and can keep them on the ball. While keeping
the trunk in side flexion, the patient is asked to move the ball forwards as
much as possible. The ball can be moved sideways to the left and right, also
maintaining the forward position by contraction of abdominal muscles. The
patient then can be taken prone on the ball with weight on extended upper
limbs. Weight shift to one side and onto the single upper limb and wheel
barrow are the activities which can be performed while prone on ball.
A B
FIGURES 11.91A and B: Training flexion of trunk in kneeling position with the
use of a ball
A B
FIGURES 11.92A to C: (A) Prone on

ball with weight-bearing on hands, (B)
raising the trunk, abdominal muscle
activation, (C) flexing the trunk fully,
C weight on knees and hands
From prone position on the ball, patient can slide forward on the ball till
the thighs rests on the ball (Figures 11.92A and B). By flexing the trunk,
weight can be shifted to the knees which are also flexed and now are resting
on the ball (Figure 11.92C). This activity is a total flexion pattern activity
on the trunk with complete weight-bearing on the upper limbs while shoulders
are flexed.
Bilateral hip and knee flexion can be attempted with the ball placed under
both knees. This activity trains lower abdominal muscles, hip flexors and knee
flexors and counteracts the extensor thrust response. After flexing both the
A B
FIGURES 11.93A and B: (A) Bilateral hip knee flexion in lying position using a
ball, (B) trunk rotation using a ball, note a band tied at thighs to prevent uncontrolled
abduction of hips
lower limbs and taking the ball off the couch, rotation to the left and to
the right can also be practiced (Figure 11.93A). If during initial stage, the
patient is unable to keep the knees together, a strap tied to both the thighs
will prevent falling off the limbs apart in abduction (Figure 11.93B).
FOOT MOVEMENTS
Sitting position can also be used in training movements of foot, toes and
as a prerequisite of weight-bearing on affected lower limb in standing. Figure
11.94 shows activation of peronei muscles using quick ice. Application of
the ice to the lateral aspect of the leg elicits the contractions of peronei muscles.
A B
FIGURES 11.94 A and B: (A) Attempting active dorsiflexion with eversion, left
hemiplegia, (B) attempting the movement after application of ice
Usually, the therapist holds one ice cube and briskly strokes the lateral side
of the leg from fibula head to little toe, two to three times. During stroking,
the patient is asked to dorsiflex and evert the affected ankle. Movement can
be performed on unaffected side also to facilitate the movement on the affected
side further.
ACTIVITIES ON MAT
Mat is the best suitable for variety of activities as it is safer for the patient.
Activities like rolling, going to prone position and kneeling are best done
on the mat. Patient is taken on the mat and rolling is practiced on both the
sides. The patient is then taken to sitting position.
A B C
FIGURES 11.95A to C: Sequence of sitting-side sitting-prone kneeling, right hemiplegia
Side sitting with the support of the upper limbs is practiced. Side sitting
is the starting position for prone kneeling (Figure 11.95). The therapist first
holds the patient from the pelvis with both hands and the hands of the patient
may hold the therapist for support. The therapist then pivots the pelvis so
that the patient takes the weight on the knees. The hands are then are extended
and put on the mat where the weight is taken on palm of hands while the
elbows are extended. This is prone kneeling (Figure 11.95C). Variety of activities
of reach outs and weight shifts can be performed in this position. Arms and
legs can be raised alternatively and weight shifts are practiced.
From the prone kneeling position, one leg is taken in front for the half
kneeling. The half kneeling can be practiced with taking both the legs in
front one-by-one. Reach outs can be practiced as a progression. Half kneeling
is a prerequisite for standing and if the patient has to go down to the floor
or has to get up from the floor, the sequence would be: sitting—side sitting—
prone kneeling—kneeling—half-kneeling—standing, and reverse (Figures
11.96A to E).
A B C
D E
FIGURES 11.96A to E: (A to C) Sequence of half kneeling, half standing—standing,

(D) kneel walking, and (E) reachout in kneeling, right hemiplegia
 Activities in Prone Kneeling

Various activities which can be carried out in prone kneeling are shown in
Figures 11.97 to 11.99.
A B
FIGURES 11.97A and B: (A) Unilateral prone kneeling with weight on affected
upper extremity, right hemiplegia, and (B) unilateral prone kneeling with weight
on unaffected upper extremity, right hemiplegia
From prone kneeling position, the patient can take the weight on the affected
side (right in this case) while the sound upper limb is taken up by carrying
out horizontal abduction at shoulder and trunk rotation to the left side. The
sound lower limb is kept in external rotation at hip and flexion at knee while
putting the foot on the ground as shown in Figure 11.97A. Similar position
can be attempted on the other side also.
A B
FIGURES 11.98A and B: (A) Prone kneeling with right lower extremity extension,
right hemiplegia, (B) prone kneeling with left lower extremity extension, right
hemiplegia
In prone kneeling position, the patient can attempt unilateral backward

extension of the lower limb one by one while maintaining posterior pelvic
tilt. Care is taken not to force the leg abruptly into extension. While one
leg is in extension, the opposite side upper limb can also be lifted up one
by one on each side as shown in Figures 11.99A and B.
A B
FIGURES 11.99A and B: Contralateral upper and lower extremity movements in

prone kneeling
A B
FIGURES 11.100A and B: Facilitation of ankle dorsiflexion with the use of a ball
TRAINING FOR DORSIFLEXION OF FOOT

Training for dorsiflexion in initial stages is easier with the knee in flexion.
A pattern of hip flexion with knee flexion in sitting elicits reflex activity
of ankle dorsiflexors. However, this activity is a mass pattern and may
not be useful functionally. For the functional use as in walking, dorsiflexion
of ankle is necessary with knee extension for heel strike. Thus, gradually
a combination of activity which uses controlled extension of knee and
dorsiflexion of ankle is used. Affected foot of the patient is placed on
4 inches high ball while the patient is seated on the chair. The patient
is asked to extend the knee while the ball is slided forward by the foot,
taking the weight on the heel. As the patient takes the weight on the heel,
dorsiflexion of ankle is elicited. The therapist may resist this forward
movement by placing the hand near distal end of tibia. Note Figures 11.100A
and B.
SPECIFIC ACTIVITIES FOR PATIENTS WITH

SENSORY INVOLVEMENT
Patients of stroke with sensory involvement pose a challenge to the treating
therapist as all the motor responses are dependent upon the sensory stimulation.
Nevertheless, in many patients, the motor movement recovery may be good
enough but there may be residual sensory perception involvement. Lack of
kinesthetic and proprioception sense require the therapist to stimulate other
intact sensory systems of the body like vision and hearing. The following
patient has a stroke on the right side of the brain resulting into left sided
kinesthetic sense and superficial and deep sensory loss with near normal
A B
FIGURES 11.101A and B: Deep pressure being applied to the sole of foot using
a medicine ball
A B
FIGURES 11.102A and B: Multiple angles isometric holds with objective activity,
left hemiplegia
motor strength. Deep pressure applied all over the body on the affected
side and also to the sound side with a medicine ball and application of
vibrations with the hand held vibrator is used, prior to the treatment to
improve the awareness (Figure 11.101). All the activities are carried out
with the patient looking at the part being treated.
Various angle isometric holds of the limbs will improve the stability of
the limbs and will also impart increased postural awareness in space. The
therapist can ask the patient to touch a specific mark with the limbs to improve
coordination (Figure 11.102).
The therapist asks the patient to touch the tip of finger of the affected
side to the tip of therapist’s finger to improve coordination and awareness
in space. The therapist can then ask the patient to give a clap at various
angles to train controlled rapid movements of upper limb. These activities
are playful and hence, patients can get training without any stress of
performing.
A B
D E
FIGURES 11.103A to E: (A) Finger-to-finger touching for coordination, left hemiplegia,
(B and C) palm-to-palm (giving a clap), left hemiplegia, (D and E) self thumb to
finger in side-lying, left hemiplegia
Activity of the hands like touching the finger tips to the tip of the thumb
can be done with the patient looking at the hand and fingers which are moving.
Note Figures 11.103D and E in which, while the patient is attempting the
finger activities, the wrist remains in flexion due to dystonic posture of the
affected upper extremity. A verbal cue to keep the wrist extended usually
counteracts this problem.
Use of both the upper limbs is advocated in training of simple tasks as
the movement of the sound side facilitates the contraction of the involved
A B
C
FIGURES 11.104A to C: Holding objects bilaterally at various angles, left hemiplegia
side. Figures 11.104A to C show the holding of simple objects with both
the hands at various angles of upper extremity. Note that the left side is the
affected side in this case. Also note that the patient constantly looks at the
task at hand.
 Coordination Activities of Upper Extremity

Coordination activities of both upper limbs can be carried out best in
sitting position. Please note the series of Figures (Figures 11.105 and
11.106), in which the patient is having left-sided hemiplegia with
incoordination and gross sensory involvement. For the same reason,
visual feedback becomes highly important. Patient assumes a sitting
position and bilateral symmetrical and asymmetrical patterns are used.
Also note that postural instability may occur if the lower limbs of the
patient are not touching the ground. In such cases, sitting on a chair
with back support and with the patient’s feet touching the ground becomes
a better position. The patient is asked to carry out alternate activity
of pronation and supination of forearm and can gently tap the pillow
kept in the lap while performing this task. Patient can also perform
B C
D E
FIGURES 11.105A to E: (A) Alternate pronation and supination, left hemiplegia

and (B to E) clapping with alternate hand on top, left hemiplegia
bilaterally symmetrical and asymmetrical activity of pronation and

supination of forearms, flexion and extension of elbows, tapping of
palmar and dorsal surface of hands, shoulder flexion and extension,
etc., in a rhythmic pattern. Use of beats of music can be effectively
used in gaining a desired rhythm of activity.
Figures 11.105A to E show controlled clapping in various ways.
Figures 11.106A to D show classic finger to finger and finger to nose
activities which can be carried out with eyes opened, progressed to eyes
shut.
A B
C D
FIGURES 11.106A to D: (A and B) Finger to finger, left hemiplegia, (C and D)
finger to nose, with eyes closed, left hemiplegia
A B
FIGURES 1.107A and B: Object holding at various levels, functional task, left
hemiplegia
ACTIVITIES FOR RECOVERING ARM

Progression of activities for upper extremity is carried out as and when indicated.
Gradually, goal-oriented activities like reaching out and functional tasks are
carried out (Figures 11.107A and B).
A B
FIGURES 11.108A and B: Mirroring movements of right upper extremity, right
hemiplegia
 Mirroring of Movements
Figures 11.108A and B show the guiding of the upper limb movements where
the patient follows the the palm of the therapist. Initially, the patient may
keep the contact of his palm with the palm of the therapist and follow it
wherever it is taken. As active movements start developing, patient may no
longer touch the therapist’s palm but can follow therapist’s palm by keeping
a few centimeters distance. Patient is asked to keep the distance between
the palms fixed throughout the movement. This activity is also useful in training
coordination and proprioception. This activity can be done on both the sides
also. The therapist challenges the patient by involving many combination of
movements which involves multiple joints at various angles. Quality of the
contractions is fantastic in the goal-oriented activities. When patient is unable
to finish a movement, guiding can be carried out. The guiding is only done
for the brain to learn a pattern of activity. Once it is learned, more active
movements are carried out. If prototype exercises are not translated to functions,
these activities become useless. It is not so that all the prototype exercises
are useless, but they have to be stopped when patient is ready to carry out
the functional activities independently. The patient may use the help of the
sound side in completing the task initially. The ultimate aim of the therapy
is to make the patient functional in all the disciplines of their lives.
 Functional Activities
Sitting position becomes an ideal platform in carrying out training of various
functional activities like grooming, dressing up, hand activities, arranging jigsaw
puzzles, stacking the beads and rings, arranging playing cards, putting on
A B
FIGURES 11.109A and B: Arranging clothes, left hemiplegia
A B C
D E F
FIGURES 11.110A to F: (A and B) Arranging playing cards, left hemiplegia and

(C) arranging jigsaw puzzle with unaffected hand, left hemiplegia, (D) arranging
beads in abacus, cerebral diplegia and (E and F) stacking rings, proper grip with
the use of splint, left hemiplegia
socks and footwear, reading, watching television and socializing, etc. (Figures
11.109 and 11.110).
Training of hand function should emphasize forearm, wrist, and finger
movements which are independent of shoulder and elbow motions. Excessive
shoulder adduction and abduction, elbow flexion, pronation of forearm, wrist
and finger flexion are typical spastic patterns that must be counteracted. Voluntary
release is generally much more difficult to achieve than voluntary grasp, and
inhibitory techniques may be necessary before extension movements are
successful. Prehension patterns should be practiced and manipulation of common
objects attempted. The therapist needs to observe these movements carefully
and to assist the patient in eliminating those aspects of performance that interfere
with effective control.
Judicious use of a splint may be required in keeping the wrist position
in few degrees of extension in carrying out hand functions, till the patient
actively maintains the position. Rubber bands may also be useful in maintaining
position of fingers, as already described above. It should be noted that active
stability achieved by patient’s own muscular control is better than passive
stabillization achieved by the use of splints.
FUNCTIONAL TRAINING
Functional mobility training, begun during the acute
phase, should be continued and extended. Prone
walking on upper limbs while patient is on a
appropriately sized vestibular ball will elicit strong
contractions in stabilizer muscles of each joint of
upper extremities on both sides. Consider the Figure
11.111, the patient is encouraged to keep the pelvis
posteriorly tilted by strong contractions of abdominal
muscles, this position trains proprioception of affected
uper extremity using the kinematic chain of the upper FIGURE 11.111: Prone
and middle section of the body, wonderfully. Care walking with upper limbs,
on a vestibular ball, left
must be observed regarding the position of elbow hemiplegia
and the wrist. If this position is used before tone
of the muscles is optimum, there is a risk of injury
to either of the joint. In initial stages, therapist can
support the patient’s affected elbow and wrist joint
manually. A variety of activities and postures can
be utilized. Additional postures such as prone on
elbows, side sitting, kneeling, and half kneeling can
be utilized, although they may not be appropriate
for older patients (Figure 11.112). Patients should FIGURE 11.112: Prone
also be instructed in strategies for getting down to on extended arms, left
and up from the floor. Therapists need to provide hemiplegia
an adequate amount of support, while allowing the patient to relearn, control

through active processing of movement. Varying the contexts (changing the
environment) is important in ensuring adaptability and generalizability of
responses.
Training in activities of daily living is usually directed by the occupational
therapist. Continuity between therapies is important to ensure that activities
are being done consistently and in the most efficient manner. The reference
for all training should be the patient’s home environment and normal daily
activity. Energy conservation techniques should be incorporated into the patient’s
daily plan.
Activities in Standing 255
C H A P T E R
12
Activities in Standing
INTRODUCTION
Correct weight bearing at an early stage provides good afferent stimulation
to the brain and is the most effective way of normalizing muscle tone. Preparation
for walking can be carried out adequately in an area of one square meter.
It is of less benefit to practice walking with a patient who is unable either
to take weight on his affected leg or bring it forward in a reasonable normal
manner unless these can be facilitated. The same applies to someone who
already walks with a poor gait pattern because repetition reinforces the experience
of incorrect movement which in time actually contributes to a reduction in
ability. It is better to assess the difficulty carefully and practice relevant activities.
That is the reason why before walking, activities in standing are aptly practiced
and mastered. Till proper weight bearing on the affected lower limb is achieved,
patient may not be allowed to walk with an abnormal gait pattern unless
absolutely necessary.
TRAINING FROM SITTING

TO STANDING
Standing up from High Bed or Plinth
The patient wriggles to the edges of the bed and puts
his affected leg to the floor without his foot pushing.
If necessary, mobilize his foot by pressing down over
the front of his ankle to ensure that his heel is on
the ground and that dorsiflexion is possible. The
therapist assists the lower limb of the patient from the FIGURE 12.1: Sitting to
knee and ensures that the knee joint does not buckle standing from a plinth,
with assistance to
and at the same time, does not snap in hyperextension affected side knee joint,
(Figure 12.1). The therapist can place one hand on left hemiplegia
the knee as described above and other may encircle the trunk for maintaining
trunk alignment as shown in the Figure 12.1. The patient may keep both
the hands clasped together to prevent synergistic movements of affected upper
extremity. If the patient is unable to fix the affected foot on the ground, it
may pose a danger, as it can slide making the patient imbalanced. To prevent
this, the therapist can put one of the feet on patient’s foot. This activity can
be performed many a times so that patient as well as patient’s caretakers
learn it properly and it can be carried out throughout the day.
Standing from a Chair

Training of standing up in a scientific method from sitting in a chair is taught
to the patient, as the correct method reduces the amount of effort by the
patient and hence, increases the effectiveness and efficiency. These methods
also employ correct muscles in normal patterns of activities and hence, even
the functional activity of standing up becomes therapeutic. Under circumstances
where a hemiplegic patient is left alone to get up by himself without help
or instruction of the therapist, usually, the extensor thrust response of the
lower limb as well as the trunk will takeover, making the patient exert the
force in the posterior direction. Due to this force production in posterior direction,
the patient will move backwards while attempting to get up from sitting. The
center of gravity moves posteriorly, out of base of support and hence, there
are increased chances for the patient to fall off. Even the chair will move
backwards due to force exerted by the knees. To counteract this, first of all,
the patient is taught to reduce extensor thrust of trunk. For this while, the
patient is seated on a chair, trunk forward bending, with arms hanging down,
is taught. Patient’s lower limbs are kept firmly on the ground and hip is kept
at neutral as far as the rotation is concerned. Figure 12.2A shows the dropping
of the affected hip (left) in internal rotation and increased side flexion of
the trunk on the hemiplegic side. This is avoided by correct holds by the
therapist initially and then by active holds by the patient (Figure 12.2B).
Figure 12.2C shows the correct position of the affected lower limb, left
in this case. Trunk of the patient is bent symmetrically and well-forward so
that the center of gravity shifts well forwards and in line of the direction
of standing. The lower limbs are kept flexed from the knees more than 90
degrees to counteract the quadriceps thrust. The ankles are thus aligned in
close chain dorsiflexion as tibia moves forward on the talus in this starting
position. Once the patient is bent well forwards, the shift of center of gravity
will automatically elicit the movement of standing.
A B C
FIGURES 12.2A to C: (A) Forward bending in sitting, hip falling in internal rotation,
(B) forward bending in sitting, thigh supported, (C) forward bending in sitting, thigh
in neutral, active, left hemiplegia
The patient’s feet are placed together with the affected foot slightly behind
the sound one to ensure good weight bearing as standing approaches. The
patient leans forward until head is vertically in front of the feet and stands
without pushing up with the hand (Figure 12.3). If the trunk and arm retract
too much at first, the patient can assist standing by pushing the arms out
in front with hands clasped together. When returning to sitting, the affected
foot remains behind and head is kept well forward while his bottom is placed
far back in the chair. The patient should not put a hand down on the chair
as this spoils the symmetry and alters the weight-bearing. Instead, the patient
should look behind and back, until there is a correct alignment with the chair.
Therapist may assist the patient for lifting the pelvis up from the chair in
a symmetrical manner. The therapist sits on a level surface on the affected
side of the patient and one hand stabilizes the lower end of femur (at the
knee) and other hand may be kept on or below the sacrum (Figure 12.4).
The patient is then asked to get up gently keeping the weight on both the
A B C D
FIGURES 12.3A to D: Active-assisted sit to stand from a chair, right hemiplegia,
note the stabilization of trunk and knee by the therapist, front view
A B
FIGURES 12.4A and B: Sit to stand, active, right hemiplegia, side view
lower limbs equal. At the same time, the therapist asks the patient to contract
the gluteal muscles, so that the femur’s upper end is engaged so that the
hip extends. This movement will assist in knee extension without the extensor
thrust. A gentle tap on the affected side gluteal muscles, at the time of getting
up, will facilitate the movement of hip extension. Therapist’s one hand can
control the knee extension and prevent exaggerated knee extension and snapping
A B
C D
FIGURES 12.5A to D: (A) Crossing sound limb over affected limb, (B) attempt
to stand with weight only on affected lower limb, wrong method without upper limb
clasping, (C and D) correct method of standing with clasp hands and weight well
forwards left hemiplegia
of the knee in hyperextension. All the way through, if the patient is able
to brace up the abdominals actively, it will help in keeping the pelvis aligned
in a posterior tilt which is required.
If the patient is unable to shift the weight well enough on the affected
lower limb, then activities which train the same are started as shown in Figures
12.5A to D.
Sound lower limb of the patient is crossed on the affected limb as shown
in Figure 12.5A. Both the upper limbs can be clasped and held in front of
the body. The therapist assists the shift of the weight on the affected side.
The patient bends little forwards and with the assistance from the therapist,
tries to lift up the pelvis off the chair. This is a difficult activity for most
of the patients and hence, is carried out with utmost care; safety of the patient
should never be compromised. Note that the optimum height of the chair
is mandatory for getting up easily. Maintaining the posture midway will help
develop the eccentric control of the muscles of the lower limbs. Note the
contraction of the abdominal muscles in Figures 12.5A to D. Once the control
of the lower limb is developed, the patient may be asked to stand fully although
with guarded knee extension. (In above mentioned activities, note the position
of the therapist on sound side as the patient may hold on to the therapist
with sound upper limb in case of imbalance).
PELVIC ALIGNMENT IN STANDING

Equal weight bearing on both the lower limbs is one of the most important
activities in the entire rehabilitation program of the hemiplegic patient. It should
be started as early as possible as, in advanced and chronic stages, it becomes
extremely difficult to train weight transference. As it can be assumed, weight
transference on the affected lower limb cannot be achieved without the adequate
shift from the pelvis, participation from the lumbar region and alignment of
the upper segments of the spine, in addition to the distal control of the lower
limb.
The therapist sits in front of the patient in level of the pelvis as shown
in the Figure 12.6. The therapist puts his feet in between patient’s feet for
spacing. Patient keeps both the hips slightly externally rotated and knees slightly
flexed. The therapist facilitates the gluteal contractions on both the sides by
tapping gently and then asking the patient to maintain the contraction. One
hand of the therapist facilitates the contraction of abdominals and hence, posterior
pelvic tilt is maintained. The therapist shifts the pelvis on the affected side
if need be, without allowing the patient to side flex the trunk on the affected
side.
A B
FIGURES 12.6A and B: Maintaining posterior pelvic tilt in standing with knees
unlocked, left hemiplegia
Figure 12.7 shows exaggerated anterior

pelvic tilt. This is caused by inadequate
abdominal and hip extensor activity. Also note
the hyperextension of the knee and shifting
of the lower end of tibia posteriorly on talus
resulting into close chain planter flexion.
Though this is a weight bearing position, it
will not give any advantages of the same as
it is mechanically at fault. Apparent length of
the affected side increases due to planter flexion
and hence, the weight bearing on affected side
is reduced to a minimum. In chronic cases,
this position leads to damage of the ligaments FIGURE 12.7: Incorrect method
of standing with anterior pelvic
of the knee, which are irreversible. No amount
tilting and increased lumbar
of splintage can tackle this issue and hence, lordisis, left hemiplegia
it should be avoided from initial stages.
UNILATERAL WEIGHT BEARING

As the patient can maintain some balance independently in standing, unilateral
weight bearing i.e., standing on one leg can be started. To take the entire
weight on the affected side, the therapist assists the patient by sitting on the
affected side. With one knee of the therapist behind the patient’s knee and
one hand in front of the knee, the therapist controls the amount of knee flexion.
Other hand of the therapist is encircled around the patient’s waist to maintain
A B
FIGURES 12.8A and B: Unilateral weight-bearing on affected side, assisted, left

hemiplegia
the lateral tilt of the pelvis and overall balance.

Then the patient is asked to gradually take the
sound leg off the floor, shifting the entire weight
on the affected lower limb (Figure 12.8). This
movement is carried out gently and balance is
maintained throughout.
Patient can practice selective knee flexion
and extension in weight bearing position in a
guarded manner. The therapist controls the
motion of the lower limb unless the patient FIGURE 12.9: Moving sound
is in a position to maintain the position himself. limb while weight-bearing on
affected side with knees
Throughout the movement, patient is asked semiflexed, left hemiplegia
to maintain posterior pelvic tilt as shown in
Figure 12.9. In the same position, the sound lower limb of the patient can
be moved in various directions as a progression.
ASSISTED ACTIVITIES WITH THE HELP OF A TABLE

Modified plantigrade is an ideal early standing posture to develop control.
The affected arm is extended and weight is shifted on to it. In addition, the
posture has a wide base support and is very stable. Progression to upright
standing activities can then occur, first with arm support, and then without
arm support.
Patient is made to stand in front of a table in a manner as shown in Figure
12.11A. This position gives adequate support to the patient’s thighs and hence,
fear of falling decreases. This reduction of fear reduces the hypertonicity through-
out the affected side. The patient is assisted to stand erect taking equal weight
on both the lower limbs while the thighs

of the patient are supported by a table
in front. Similarly, patient can take
weight on both the upper limbs by
keeping them on the table top as shown
in Figure 12.10. The therapist aligns
the spine of the patient as required. The
patient is then asked to lift the sound
leg off the ground and take entire weight
on affected lower limb only. Abdominal
muscles and gluteal muscles contractions
tilt the pelvis posteriorly and align the
femur so that knee joint remains neutral
A B
and does not fall into hyperextension. FIGURES 12.10A and B: (A) Taking
Note Figures 12.11A and B and weight on upper limbs in standing, right
difference in position of pelvis and knee hemiplegia, (B) taking weight on clasped
in both of them. hands with wrist in extension
The patient is made to stand on a
foam wedge in a stride position with the affected leg in front as shown in
Figure 12.12A. The front thigh of the patient is supported by the table. Both
the upper limbs are clasped and taken in front of the body. The therapist
guides the pelvis in a posterior tilt and assists the weight transference on
the affected front leg. Note the knee joint which is in few degrees of flexion.
The patient is then asked to flex the trunk and put the weight on both the
elbows on table top. Note the weight on the heel as the ankle dorsiflexes.
The use of a foam wedge trains the proprioception and balance. The same
A B
FIGURES 12.11A and B: (A) Standing straight with thigh supported by a table,
left hemiplegia, note anterior pelvic tilt which can be corrected and (B) weight-
bearing on affected side with knee in neutral or slight flexion in standing, left hemiplegia,
pelvis posteriorly tilted
A B
FIGURES 12.12A and B: (A) Stride standing on a foam wedge and (B) stride
standing on a foam wedge with flexion of trunk, left hemiplegia
activity can be done with the sound (right) leg in front and training of affected
side ankle plantar flexors can be carried out. A contraction of abdominal muscles
is maintained throughout along with relaxed breathing.
Weight bearing on Extended Arm

Practice of weight bearing through the extended
arm in standing is carried out by placing both
the upper limbs in external rotation position from
shoulder, extension from elbow, supination of
forearm, wrist and fingers extension, and thumb
abducted and extended (Figure 12.13). As a part
of progression, only the affected side can be
used for weight bearing. Elbows can be flexed
and extended in the weight bearing position to
train activities of triceps in close chain position.
The patient can flex the lower limbs while FIGURE 12.13: Weight-bearing
the upper limbs are still on the table either in on both upper limbs in external
rotation of shoulder, right
front or behind as shown in Figures 12.14A and hemiplegia
B. While flexing the trunk, both the hands are
kept on table as shown. If affected hand slides off the table, it can be secured
by putting sound hand on top of it. This activity trains close chain upper
limb function of shoulder flexion primarily with flexion pattern of trunk. Both
the upper limbs can be placed on a table which is kept behind and weight
bearing posteriorly can be carried out. In this position, external rotation of
the shoulder is easily maintained. As a progression, therapist can ask the patient
to flex the lower limbs and squat as far as possible. If the patient is unable
A B
FIGURES 12.14A and B: (A) Weight bearing on upper limbs with trunk flexion,
right hemiplegia and (B) weight bearing on upper limbs with shoulder extension
and knee flexion, right hemiplegia
A B
FIGURES 12.15A and B: Table mopping, right hemiplegia
to maintain position of affected hand on table then, the therapist can assist
in doing so.
Patient can carry out mopping activities, once the weight bearing on the
upper limb in standing improves. If motor control of the affected side is not
sufficient enough, sound hand is placed over the affected hand and assisted
mopping can be carried out in full range of motion; forward backwards and
side to side (Figure 12.15). This activity trains functional movements of upper
limb. It also helps in normalizing muscle tone of affected upper limb. Partial
weight given through affected upper limb facilitates proprioception and helps
in awareness of position of that part in space.
STEP-UP ACTIVITIES
While standing on patient’s affected side, the therapist draws his weight towards
himself, giving as much support as required. The therapist then asks the patient
to take steps on the bolster with the sound leg, preventing the knee from
snapping back into extension by keeping the hip well forward.
A bolster is placed in front and the patient is asked to keep one leg on
it (Figure 12.16). The bolster being a movable surface, the patient may have
to control the lower limb and if not, the extensor thrust of the lower limb
will slide the bolster forwards. Adequate support by the therapist may be
required initially. So as explained before, support from the pelvis is given.
If need be, patient may hold on to a stable object by the sound limb but
care must be taken not to allow the patient to lean on the object of support.
Training is done for both the lower limbs. Affected side raises will train the
hip flexion and knee flexion with dorsiflexion of ankle in a controlled manner.
The sound leg raises will train the affected side weight bearing and balance.
Bolster can be moved back and forth in a controlled fashion to train selective
motor movement in standing (Figure 12.17).
A B
FIGURE 12.16: Stepping FIGURES 12.17A and B: Dynamic activities on
up on a bolster with affected a bolster, sensory stroke, left hemiparesis
lower limb, left hemiplegia
WEIGHT BEARING ON THE AFFECTED LEG

In standing position, ask the patient to place his sound foot lightly on and
off a step in front of him. Repeat the activity with the step placed well, out
to the side. Encourage the patient to keep his affected hip against your hip.
Prevent the patient’s knee from locking back, and ask the patient to draw
large letter on the floor with the sound foot, ensuring weight bearing on a
mobile leg. Make the patient stand on the affected leg and lightly place the
sound foot at a right angle in front or behind the other foot, without transferring
the weight onto it. If the activity is performed accurately, it helps the patient
to gain control of the hip abductors and extensors. Place the patient’s affected
leg on a 15 cm (6 inches) step in front of him. With your hand pushing
down on the knee and keeping the weight well forward, the patient steps
up onto the step. Practice stepping down with his sound leg placing further
and further back, and tapping it on the floor behind, keeping the weight forwards
on the affected leg. Put the affected leg on the step and help the patient
to push up and step right over and back again (Figures 12.18A and B).
Patient is trained for side lifts of affected and sound lower limb as shown
in Figures 12.19A to C. Here, the affected side is left. The therapist stands
behind the patient with the pelvis fully supported and maintaining the balance
of the body. The affected upper limb is held in a reflex inhibiting position
(shoulder extension, external rotation, elbow extension, forearm supinated and
wrist and fingers extended and thumb extended and abducted) as shown in
Figures 12.19A and B. A small stool of optimum height is kept at the affected
side first. The patient is asked to take the affected lower limb sideways, upwards
and to put the foot on the stool. The therapist guides the pelvis so that it
A B
FIGURES 12.18A and B: (A) Reaching outs with affected lower limb in front, left
hemiplegia, and (B) reaching outs with sound lower limb in front, left hemiplegia
A B C
FIGURES 12.19A to C: (A) Putting affected foot on a step sideways, left hemiplegia,
(B) note hip internal rotation with adduction on left side, and (C) putting sound
foot on a step sideways, left hemiplegia
does not fall into gravity and asks the patient to maintain the position. Gradually,
the assistance given by the therapist is reduced and the activity is carried
out more and more independently. Similar side lifts can be carried out by
the sound lower limb also. Note the difference in position of pelvis in Figures
12.19A to C when the sound limb is lifted and when the affected limb is lifted.
Posterior Pelvic Tilts against the Wall

Symmetrical weight bearing on both lower extremities and knee control can
be trained along with contraction of abdominal muscles in standing position.
Patient is made to stand with the back totally supported by a wall. Both the
feet are kept apart in the line of pelvis. Both the hips are kept slightly externally
rotated and knees are flexed to about 15 to 20 degrees. Both the feet are
kept firmly on the ground. The patient is then asked to posteriorly rotate
pelvis by contraction of abdominal muscles in front and gluteal muscles at
the back so that lumbar lordosis is obliterated (Figure 12.20). A small ball
can also be kept at the lumbar region to “feel” flattening of the lumbar spine.
This activity helps in maintaining a symmetrical and correct posture which
eventually helps in all functional tasks.
A B
FIGURES 12.20A and B: Practicing posterior pelvic tilts, supported by wall, left
hemiplegia
TRAINING PLANTAR FLEXION

Selective motor activity of plantar flexion in standing position is essential
for terminal stance phase and push-off of gait cycle. Contraction relaxation
coupling of dorsi and plantar flexors is required for aligning tibia in relation
to talus and femur, thus providing stability at ankle and knee joints, respectively.
Use of the gait cycle in training plantar flexors is usually incorporated. The
patient is made to stand in a stride standing position with the sound limb
A B
FIGURES 12.21A and B: Plantar flexion in stride standing position, left hemiplegia
A B
FIGURES 12.22A and B: (A) Toe standing, assisted but still asymmetrical, left
hemiplegia, and (B) toe standing, symmetrical, left hemiplegia
in front and affected limb behind. The patient is then assisted to shift the
weight onto the sound limb while concentrating on plantar flexion of the
affected limb which is behind. Few degrees of knee flexion may be associated
to unlock the knee while doing so. Please note Figures 12.21A and B.
If the patient fails to plantar flex the ankle actively, the therapist assists
by lifting the heel off the ground as shown in Figure 12.21B. Standing up
on the toes with the support of the wall can also be carried out as it would
become a bilaterally symmetrical pattern of activity (Figures 12.22A and B).
TRAINING SELECTIVE KNEE FLEXION IN

STANDING
To counteract exaggerated extensor thrust response in standing, selective knee
flexion is started as soon as possible. The patient is asked to flex the affected
A B
FIGURES 12.23A and B: (A) Active knee flexion in standing, left hemiplegia, note
reactions of trunk, and (B) assisted knee flexion in standing with stable trunk, left
hemiplegia
knee in standing while the therapist prevents the associated unwanted contraction
in trunk and hip region by stabilizing upper trunk with one hand and pelvic
region with the other. The therapist can hold the patient’s ankle (while the
knee is flexed), in between his both lower limbs. Eccentric contraction of
hamstring can be trained when the patient is asked to lower the leg which
is flexed from the knee assisted by the therapist. Please note Figures 12.23A
and B. Eccentric contraction of hamstring is useful in deceleration of the
leg in terminal swing phase of the gait.
DYNAMIC ACTIVITIES FOR

LOWER LIMB CONTROL AND GAIT
Releasing the Knee and Moving the Hemiplegic Leg
(Preparation for the Swing Phase of Gait)
The patient stands with his feet close together. Guide the pelvis forward and
down to release the knee on the affected side. Instruct the patient to straighten
it again, without pushing the whole side back. The patient must remain in
contact with the floor; this is only possible if the pelvis drops forward. The
same activity is practiced in step standing with the affected leg behind, and
the weight forwarded over the extended sound leg. The patient stands with
the weight on his sound leg. Facilitate small steps backward with the other
foot by holding the toes dorsiflexed and instructing not to push down. Do
not allow to hitch the hip back. The patient walks sideways along a line
crossing one foot in front of the other. When the sound leg takes a step,
the affected limb must be kept well forward so that his knee does not snap
A B
FIGURES 12.24A and B: Movements of affected lower limb in standing using a
ball, left hemiplegia
back into extension.

Patient is trained to move the affected lower limb in a controlled fashion
in standing position by using a vestibular ball of optimum size as shown
in Figures 12.24A and B. The patient puts the affected foot on the ball, while
taking majority of the weight on the sound lower limb. The patient then moves
the ball in various directions starting from single plane activity progressing
to multiplanar activities. The therapist may guide or control the movements
by putting his own foot on the ball. This way, all the functional movements
of the lower limb can be trained for direction of the movement, range of
movement and velocity of movement. During this activity, the basic correction
of the posture as explained before is strongly advocated. Similar activity can
be carried out by putting the sound foot on the ball while the affected lower
limb maintains the balance of the body in a weight bearing position.
Training for Taking Steps

Figures 12.25A and B show the correct method for avoiding hyperextension
of knee and exaggerated extensor thrust while walking. The therapist stabilizes
the patient’s affected knee joint in a few degrees of flexion in the stride position
as shown in the above Figure. The knee joint is held in partially unlocked
position and the hip is held in extension while the foot rests completely on
the ground. The patient is asked to take a step forward with the sound lower
limb. Any exaggerated movement on either side should not be allowed at
all. As this movement happens, the therapist guides the affected knee into
few degrees of flexion and ankle in few degrees of planter flexion, simultaneously
maintaining adequate extension at the hip by asking the patient to contract
gluteal muscles. This activity is of paramount importance in training various
phases of gait cycle. In initial stages, adequate support for maintainance of
A B
FIGURES 12.25A and B: Taking step with sound lower limb, guiding done for
affected limb, left hemiplegia
the balance is usually required and hence promptly provided.

The affected limb swing phase can also be trained with the therapist guiding
and controlling the active motion throughout the range.
Abnormal Gait Pattern

To walk upright on a narrow base has played a key role in our life style
for over two and half million years. This ability has enabled us to acquire
numerous challenging skills like running, jumping, dancing, rope walking,
etc. To support the upright posture on a narrow base on either both the legs
or one leg support demands a highly complex postural reaction to maintain
balance and postural adjustments throughout the ongoing gait sequence. In
walking, the shift in position of torso and hips over the feet initiate the movements
in each foot. The ability to stand up and sit down symmetrically and safely
plays an integral role in normal functional walking. Normal gait pattern is
automatic and symmetrical; there is continuous shift of center of gravity in
posterior, lateral and forward directions. The femoral trochanters face anteriorly
and the hips move forwards in a smooth wave-like pattern. The rhythm, the
step length and support time on each leg are equal.
Factors responsible for abnormal gait pattern
 Primary neurogenic
Sensory motor impairments as a result of the lesion in the CNS
– Alteration in muscle tone, spastic extensor tone
– Inadequate or distorted tactile-kinesthetic information from within and
from the environment
– Depression of motor activity, weakness or paralysis of the muscle
– Loss of selective motor activity, reciprocal inhibition and movement
dexterity
– Abnormal coactivation of the weak muscles emerge as patient attempts

to load the affected limb resulting in altered normal biomechanics in
the leg
– Insecurity and fear of fall due to inadequate balance and equilibrium
reactions affecting the normal postural adjustments during the gait
sequence.
 Adaptive patterns
Adaptive patterns occur as a result of faulty habits
– The patient attempts to walk in his best possible manner irrespective
of proper balance and movement sequence
– Improper inputs and facilitation given by the team members and family
– Adverse neural tissues result in shortening of soft tissues, muscles and
musculoskeletal contractures and joint stiffness. Muscle length shortening
or contractures are observed in truncal muscles, low back extensors, hip
flexors specially rectus femoris, hip external rotators and iliotibial band,
adductors, knee flexors, calf muscles and occasionally in tibialis anterior
and extensor hallusis longus. The adverse tissue tensions alter the
biomechanics in the leg restricting forward weight shift of the body mass
over the stance leg.
Main difficulty is a short stance phase on the hemiplegic leg with a quick
active swing phase and long stride length. This results into prolonged stance
phase and abruptly ending swing phase of the normal leg.
Stance Phase
Stance phase sets up the most favorable condition for the swing phase. Many
problems observed in the swing phase are related to stance phase. An
asymmetrical flexed posture with the center of gravity well behind the normal
line make it difficult for the patient to extend the trunk on his hips and to
shift body weight forward over to supporting leg. The extensor spasticity,
the hyperextension in the knee, weakness in the extensors and truncal muscles
and inadequate postural adjustments result in flexion of the trunk on hips
(flexion attitude). Shortened and inactive plantar flexor reduces the force for
the push off.
Swing Phase
The problems observed in the stance phase cause difficulty in achieving a
low energy swing phase following a forward step with the unaffected leg.
The swing phase of the sound leg too is affected, the foot falls flat on the
ground without heel strike and the knee remains 15–20 degrees flexion on
floor-foot contact. The patient actively extends the supporting leg to raise
his center of gravity in an effort to shorten the hemiplegic leg for the swing
phase. The swing phase of the hemiplegic leg is a high-energy active movement.
The patient hitches the pelvis up and with circumduction brings the leg forward
in total extension pattern. The floor-foot contact is either on the toes, ball
of the foot or in supination due to spastic pull of tibialis anterior and tibialis
posterior and loss of their inhibition. There is an inability to transfer the weight
adequate over the sound leg to free the affected leg for swing phase. The
foot continues to push against the floor for clearance, the patient translates
the weight sideways to the hitching the pelvis. The patient literally walks
sideways.
Typical Characteristic Features

 Loss of automatic gait pattern
 Significantly reduced speed and stride length
 Alteration in cadence and rhythm
 Short stance phase on hemiplegic leg and active high energy swing phase
 Long step length with the hemiplegic leg
 Increased double leg support
 Abnormal coactivation of truncal and leg muscles alter the biomechanics
of the leg
 Inadequate balance, postural adjustments and weight transfers.
Re-education and Gait Facilitation

Restoration of functional walking plays a major role in the rehabilitation of
the CNS lesions. A hemiplegic patient, who stands up asymmetrically, experiences
difficulty to bear weight on his hemiplegic leg and maintain an upright posture.
The asymmetrical posture affects the gait sequence from very first step. To
facilitate gait, the therapist uses the skill in his hands to prevent all the observed
difficulties. The hands either assist the selective movement pattern or inhibit
and prevent unwanted activity. Quoting Ms. Bobath (1976), “All the various
phases of walking can be prepared for in standing.” To prepare the patient
for a reasonably good gait pattern balance, stance and weight transfer should
be practiced in standing for the stance phase. The patient requires to release
his spastic muscles at hip, knee and ankle for push off and to swing the
leg forward. In the mid swing phase, patient must control his extending knee
for a well-timed heel strike or floor-foot muscle. These preparatory exercises
assist the patient to develop a better and stable walking pattern.

The treatment goal aims at:
 Bearing equal weight and balance on both the legs and on each individual
leg
 Shifting the weight laterally and forward
 Walking without aids and with good speed and rhythm
 Ability to regain balance
 Learning to walk sideways and backwards to cross the steps and to walk
on uneven surfaces
 Ability to go up and down the stairs
 Walking with confidence and stability on the streets.
Gait Training
Walking is usually initiated early on, before selective movement and balanced
control are achieved. It can be used to motivate patients and minimize
deconditioning but increases the risk of developing persistent and faulty habits.
While ambulation, aids such as quadripod canes assist early mobilization; they
can also distort balance, promoting an excessive weight shift on to the unaffected
side. Gait training should focus on the attainment of control in the selective
movements necessary for gait with appropriate timing. Specific movement
deficiencies should be identified and corrected. Initially, this may require focusing
on the specific muscle actions or combinations in other less demanding postures
and then practicing them in an upright position (e.g. lower trunk rotation is
practiced first side-lying, then kneeling, plantigrade, and finally standing and
walking). Performance is context specific. The therapist cannot assume carrying
over from practice in one position to another. Persistent posturing of the upper
extremity in flexion adduction during gait can be controlled through positioning
the hemiplegic arm in extension and abduction with the hand open.
Orthosis in Gait Training

An orthosis may be required when persistent problems prevent safe ambulation.
Prescription will depend upon the unique problems each patient presents. The
pattern of mediolateral instability and weakness at the ankle and knee, and
the extent and severity of spasticity and sensory deficits of the limb are the
major factors to be considered when prescribing an orthosis. Temporary devices
(e.g. dorsiflexion assists) may be used during the early stages while recovery
is proceeding, to allow the patient to practice standing and early walking. Permanent
devices are prescribed once the patient’s status is relatively stable. Extensive
bracing using a knee-ankle-foot orthosis

(KAFO) is rarely indicated or successful.
An ankle-foot orthosis (AFO) is
commonly prescribed to control deficient
knee and ankle and/or foot function (Figure
12.26). These may include a molded AFO
(polypropylene AFO, plastic spiral AFO,
plastic solid ankle AFO), or conventional
double upright/dual channel AFO. In this
latter device, a posterior stop can be added
to limit plantar flexion while a spring assist
FIGURE 12.26: Ankle-foot orthosis,
can be added to assist dorsiflexion. An air- left hemiplegia
stirrup ankle brace can be used to provide
mediolateral stability at the subtalar joint while allowing dorsiflexion and plantar
flexion. Knee problems in hemiplegia can usually be controlled by adjusting
the position of the ankle. An ankle set in 5 degrees plantar flexion stabilizes
the knee during mid stance. A patient with mild knee hyperextension without
foot and/or ankle instability may benefit from the application of a Swedish
knee cage to protect the knee. The therapist must frequently reassess the patient’s
motor function and the need for an orthosis, since continuing recovery may
warrant a prescriptive change or discontinuing the use of a device.
Various Activities During Gait

Cycle
Each phase of gait cycle is trained
individually on both sides before actual
walking is begun to avoid abnormal reflex
activity paterns to takeover. During
walking, to counteract the flexor synergy
of the affected upper limb, one of the
method can be used is explained below.
The patient is given a large ball to hold
with both the upper limb while walking
a shown in Figure 12.27. This activity also
facilitates movement of thoracic and
lumbar region. Mass synergistic pattterns
of activities are reduced as the patient
FIGURE 12.27: Walking with a large
voluntarily tries to hold the ball with both ball held in front, assisted, left
the upper limbs. hemiplegia
The patient can also walk with both the hands clapsed together in front
in initial stages. Furthermore, the therapist may hold the affected upper limb
in reflex inhibiting posture (shoulder extension; abduction and external rotation;
elbow extension; forearm supinated; wrist and fingers extension; thumb extension
and abduction). The rotation of upper trunk in either direction is essential
for normal arm swing during walking. This can be trained by the therapist
by holding both the upper limbs from either behind or front and assisting
A B C
FIGURES 12.28A to C: Gait facilitation by guiding the pelvis, right hemiplegia
rotation of the upper trunk (Figure 12.28).

The therapist can assist the pelvic movement of the patient while walking
from behind. The therapist holds the pelvic rim of the patient on both the
sides and assists the pelvic motion in the following manner.
 Swing phase: Pelvic movements upwards and
forwards progressing to forwards and
downwards during heel strike
 Heel strike: Downward pressure
 Stance phase: Downwards and backwards.
The above movements are done in a cyclic
fashion without changing the hold and continuity
is maintained throughout the movement.
For training dorsiflexion during walking, the
therapist tips the patient backwards from pelvis.
This movement elicits the response of dorsiflexion
of ankle. The patient is then asked to carry out
FIGURE 12.29: Tipping back-
the dorsiflexion actively in standing position. As wards for dorsiflexor activity,
shown in Figure 12.29, the therapist holds the left hemiplegia
patient from the arms on both the sides while the patient places both the
hands on the therapist’s chest in front (Figure 12.30). The therapist in this
position can resist the forward motion of the patient’s body, thus training
the abdominals dynamically. The activity should be smooth in nature and no
amount of jerky activity is allowed. This activity also trains the affected upper
A B
FIGURES 12.30A and B: Resisted gait training, left hemiplegia
limb in weight bearing in front and hence, decreases the chances of flexor
synergy while walking.
The same position can be easily utilized for resisting the action of walking.
It is very useful in training functional walking in normal environment. Resisted
walking facilitates normal gait pattern.
Gradually, as the patient progresses, the upper limbs can be removed from
the therapist’s chest and the therapist can provide resistance to the movement
by applying pressure over sternum. This activity trains the appropriate alignment
of the of the body parts while walking so that the center of gravity is maintained
insde the base of support. Rather than holding the patient for giving support,
the therapist can use this activity as the patient feels supported and hence
fear of fall decreases. As it can be noted from the Figures 12.31A and B,
reisted walking will elicit dorsiflexion of the affected side and hence, heel
strike is facilitated. A combination of many such techniques may be required
to train individual phases of the gait.
Advanced gait training should continue to emphasize selective movement
control and normal timing. Gait can be practiced forwards, backwards, sideways,
and in crossed pattern (braiding) (Figure 12.32). Elevation activities (stair climbing,
step over step; over and around obstacles) and community activities (on different
terrains) should also be practiced. Timings can be improved through the use
of resisted progression technique, stimulating music, or a treadmill. At this point
A B
FIGURES 12.31A and B: Reisisted walking with one hand, left hemiplegia, note
facilitation of dorsiflexion of ankle on affected side in Figure B
A B
FIGURE 32: Braiding, crossing FIGURES 12.33A and B: Pattern walks for
one leg in front of other leg while training coordination of step length
walking, right hemiplegia
in recovery, the patient should be able to monitor his or her own performance
and reorganize and initiate corrective actions. The patient should be able to
vary speed of walking and maintain performance while confident walking in
all types of situations likely to be encountered in daily life. For training steps
length, various marks on the floor can be made and the patient is asked to
walk according to them. For an example, foot marks are placed which are at
an appropriate distance with each other and the patient is asked to place the
foot right on them. This activity can be made more challenging by altering
the distance between the marks frequently (Figure 12.33).
In many cases, the basic structure of the patient’s lower limbs are not stable
to carry out complete weight bearing on the lower limbs. Orthopedic injuries
or previous surgeries to the back or lower limbs may cause instability of
the lower limbs. Neurological involvement like stroke decrease the motor control
of the muscles and hence, more strain occurs on the ligaments. Thus, modification
A B
FIGURES 12.34A and B: Use of an AKBK splint in a patient with TKR, left hemiplegia
of activities has to be carried out and a patient specific customized approach

is carried out.
Figures 12.34A and B show an elderly female patient with left-sided
hemiplegia. She had undergone total knee replacement surgery before two
years of the onset of stroke. Due to these events, there was gross instability
of the knee joint and hence, all the weight bearing activites were carried
out using an AKBK (above knee below knee) splint which can be seen in
Figures 12.34A and B. Apart from the splint, adequate manual support was
also provided by the therapist.
The lunges as shown in the Figure 12.35 are a helpful tool in gaining
dynamic weight bearing on the lower limbs. The patient is asked to keep
the trunk stable and erect throughout the movement and weight is shifted
on lower limb on one side. The patient stands with both the feet apart and
is firstly asked to shift the weight on sound side as it is easier to learn. Once
a correct pattern of the lunges is learnt, the therapist asks the patient to lunge
on the affected side. Lunges are carried out as low as the patient can maintain.
Forward lunges can also be practiced by keeping one leg in front. The forward
limb is bent while the back limb is kept extended form the knee. Along with
the weight shift forwards on the lower limb, the patient can be asked to reach
A B C
FIGURES 12.35A to C: (A) Lunge to left, right hemiplegia, (B) lunge to right, right
hemiplegia, and (C) forward lunge with right leg in front, right hemiplegia
out with the affected upper limb in front which will elicit the response of
wrist and fingers extension. Please note the Figure 12.35C.
STAIRS
A B C
FIGURES 12.36A to C: Stair climbing, unsupported, right hemiplegia
Climbing stairs at an early stage, even before independent gait is achieved,

is both therapeutic and functional. The patient is taught to perform the activity
in a normal manner, i.e. one foot on each step and without the support of
the hand-rail (Figures 12.36A to C).
Ascending
In the early stage, it may be necessary for the therapist to lift the affected
leg on to the step rather than allowing the patient to struggle. Support the
affected knee as steps are taken with the sound leg and keep the weight forward.
The therapist can hold the patient from pelvis by remaining on the affected
side by one hand and by the other hand can control the affected lower limb
from the knee joint. As said earlier, the therapist can assist the patient in
keeping the affected lower limb on the step. By guiding the pelvis well forwards
and at the same time, keeping the affected side knee joint stabilized, the therapist
asks the patient to climb up. Snapping of the affected knee joint is prevented
by proper stabilization. Rail on unaffected side can be used for support but
the patient is not allowed to transfer the weight on sound side completely.
The patient can also be taught to climb the step by putting the sound lower
limb first. In this activity, the therapist stabilizes the affected lower limb which
is supporting the body weight while the sound lower limb is kept on the
step. Along with providing adequate support for balance, the patient is asked
to keep the sound lower limb very slowly and in a controlled fashion to achieve
smooth weight transference on to the affected side. During this activity, the
therapist can stabilize the patient’s affected side knee joint in few degrees
of flexion to prevent hyperextension.
Descending
Guide the pelvis well forward on the affected side as the patient puts the
foot down preventing the leg pulling into adduction. The therapist’s hand on
the patient’s knee will give support as steps are taken down with the sound
leg. The grip of the therapist on the patient is similar to that during the stair
case ascending. While putting the affected lower limb down on the step first,
the therapist has to control the hip adduction in addition to the knee control.
Care should be taken that the foot lands completely in the middle of the
step, as half foot on the step can trigger fear of fall or ankle clonus. While
putting the sound lower limb first, the therapist controls the knee, hip and
pelvis movements on the affected side till the active eccentric control develops.
DYNAMIC BALANCE ACTIVITIES

Postural reactions are organized in to a limited number of motor strategies
or synergies. Patients with stroke typically exhibit delayed, varied, or absent
responses. Latency, amplitude, and timing of muscle activity are all
characteristically disturbed. It is, therefore,

important to proceed slowly in training and
to select challenges appropriate for the
patient’s level of control. The patient’s
attention should be directed to the
appropriate muscle activity and strategies
needed to maintain balance. Postural
biofeedback provided from standing on a
force plate system has been effective in
improving balance responses in patients.
There are a number of different balance
devices currently on the market that can
be utilized in training. Finally, safety
education on the prevention of falls is a A B
critical factor in ensuring maintenance of FIGURES 12.37A and B: Forward
the patient’s hard-won functional inde- weight shifts on affected side on tilt
board, left hemiplegia
pendence.
The tilt board is not only essential for treatment but is also most helpful
when re-educating correct transference of weight.
The therapist stands on the floor behind the patient and helps to step on
to the tilt board with one foot on either side. The patient’s feet should be
parallel to one another throughout the exercise (Figure 12.37A). Tilt the board
slowly from side, pausing at each extreme to correct the patient’s position
and make sure that the hip comes right above the foot, that the side lengthens
and that the pelvis does not rotate (Figure 12.37B).
The therapist should take care that the patient takes full weight on the
affected lower limb as this is not possible actively during the acute stage.
The therapist assists the pelvis from behind and ensures that hip is extended
on the affected side. The back leg which is unaffected will bend from the
knee, while the affected front leg remains extended at the knee.
When taking the sound limb in front, the back sided affected leg has to
flex from the knee and hence, there is closed chain dorsiflexion at the ankle
joint and close chain flexion at the knee which are desired movements.
When doing side to side movements, there is alternate flexion and extension
at the knee with alternating weight bearing on each leg. The trunk should
follow the limb which has the weight. If this movement is not possible actively,
assistance is given by the therapist (Figure 12.38).
When adequate balance is achieved and the patient is able to maintain
balance while maintaining posterior pelvic tilt, more dynamic activities like
A B C
FIGURES 12.38A to C: Weight shifts sideways on both sides on tilt board, left
hemiplegia
reaching outs while on the vestibular board can be started. Ball catching and
throwing, while on the board will test the skill of the patient tremendously.
Care should be taken for the safety of the patient.
Proprioception can be furthermore attenuated by taking the patient on
A B
FIGURES 12.39A and B: Marching on FIGURE 12.40: Reach outs with a ball,
a foam wedge with eyes closed, left on a foam wedge, left hemiplegia
hemiplegia
A B
FIGURES 12.41A and B: Trunk rotation with supination of forearm, on foam wedge,
left hemiplegia
the foam wedge. The patient is asked to first maintain the balance. Secondly,
the patient is asked to do marching on the wedge first with the eyes open
and then with the closed eyes. The progression can be made by reaching
out activities while the patient is on the foam wedge (Figures 12.39 and
12.40).
While the patient stands on the foam wedge, active rotation of the trunk
can be used in eliciting external rotation at shoulder and supination at forearm.
The patient is asked to carry out the above mentioned, actively on both the
sides (Figure 12.41). Assistance by the therapist in the movements of trunk
and upper limb can be given if needed. These activities are carried out in
rhythmic fashion.
A B C D
FIGURES 12.42A to D: Wood chopping: (A) Down and to the right, (B) up and
to the left, (C) down and to the left and (D) wood copping, up and to the right,
left hemiplegia
PNF WOOD CHOPPING

Diagonal patterns of trunk with upper limbs clasped together can be carried
out easily in standing. Patient stands erect with equal weight bearing on both
the lower limbs with the hands clasped together. The patient is then asked
to take both the hands down towards right foot by bending and rotating the
trunk towards right side (Figure 12.42A). From this position, the upper limbs
are taken up and towards left by extending and rotating the trunk towards
left side (Figures 12.42B and C). Similar activity can be performed on other
side also (Figure 12.42D). Throughout the movement, patient’s head and neck
moves in the direction of the motion and the eyes follow the moving upper
limbs. If the patient is unable to flex the trunk completely with knee in extension
due to soft tissue tightness, flexion of the knee can be allowed. This activity
strengthens the trunk musculature as well as stretching of tight structures of
the trunk is duly carried out. The affected upper limb moves in a reflex inhibiting
posture and hence, spasticity is reduced. As a progression of this exercise,
the patient may hold a ball in both the hands rather then clasping. All these
movements can be resisted manually by the therapist by either applying pressure
over the moving clasped hands or on the moving trunk. This activity is also
used in strengthening the stabilizers of scapula like serratus anterior and also
helps in improving dynamic balance reactions. It should be noted by keeping
both the knee slightly flexed, eccentric contraction of the stabilizers of the
lower limb are carried out.
UPPER LIMB ACTIVATION
A B
FIGURES 12.43A and B: (A) Raising sound upper limb and (B) raising affected
upper limb, left hemiplegia
FIGURE 12.44: Bilateral FIGURE 12.45: Bilateral abduction of both upper

elevation of both the upper limbs, note the movements of scapula on both sides,
limbs, note movement of left hemiplegia
scapula on both sides, left
hemiplegia
All the movements of the upper limb, especially that of scapula and shoulder
can be checked and treated in standing position for the ease of application.
Any assessment which needs to be carried out is done by proper exposure
of the part. As shown in Figures 12.43A and B, the left side of the patient
is affected side and proper observation alone can show the abnormality of
the motion if any. Figure 12.43B shows the exaggerated outward rotation of
scapula with protraction on the affected left side. Due to this reason, the
head of the humerus fails to align with the glenoid cavity at optimum level
and hence, full range of shoulder flexion and abduction is not gained. Figure
12.44 shows the dynamic alignment fault while attempting to raise both the
upper limbs.
Winging of the scapula on the left side can easily be seen when the patient
attempts active abduction of both shoulders. On the right side, proper alignment
of the scapula can be noted.
After studying the abnormal motion on the affected side, the therapist can
treat the disorder by fixing the scapula and aligning it to the thoracic cage.
This can be done passively in the initial stage of treatment and later on, active
fixation can be achieved by contraction of the muscles which stabilize the
scapula. The therapist should not fix the scapula in a specific position while
the arm is in motion , but rather the therapist assists the normal biomechanical
scapular motion dynamically (Figure 12.45). As seen in the above case, if
the motion of the scapula on the affected side is exaggerated at two levels,
i.e. outward rotation and protraction, then the therapist fixes the scapula from
start of the movement and asks the patient to raise the arm. All throughout
the movement, the therapist stabilizes the scapula so that the outward rotation
and protraction doesnot occur more than that of the normal side, and allowing
the scapula to move normally in the entire range of motion. The therapist
can also assist the movements if active contraction of the scapular muscles
fails to produce desired movements.
The above explained activity can be done in any part of the body with
proper understanding of the biomechanics and kinesiology. Comparing the
movement to that of the normal side is the best guide for the therapist. To
A B C
FIGURES 12.46A to C: (A) Holding a ball in front with both upper limbs, (B) holding
the ball with affected upper limb, and (C) holding the ball with sound upper limb
while the affected upper limb is tried to elevate, left hemiplegia
maintain the corrected position, scapula can be taped adequately.

The patient stands erect with a ball of optimum size held in front of the
body with both the upper limbs as shown in Figure 12.46A. This activity
decreases the tone of the spastic muscles on the affected side. This activity
is a bilaterally symmetrical pattern of activity and hence, activity on the affeccted
side will be enhanced in accordance with the movement on the sound side.
As the patient becomes comfortable in this position, the sound upper limb
can be raised upwards while the affected upper limb holds the ball against
the body as shown in Figure 12.46B. The patient is then asked to lift the
affected upper limb upwards while the sound limb holds the ball. Note that
the affected side is left in Figures 12.46A to C. Also note that even though
motor control on the affected left side is inadequate to produce sufficient
movement, the same affected limb can hold the ball alone without the support
FIGURES 12.47A and

B: (A) Holding a ball with
upper limbs on side, left
hemiplegia, and, (B)
squats while holding a
A B ball, left hemiplegia
of the sound upper limb. As the motor control of the upper limb develops,
the ball can be held with the upper limbs kept sideways on the ball as shown
in Figure 12.47A. This requires supination of forearm and external rotation
of the shoulder. Ball can be moved sideways to the right and to the left with
the rotation of the trunk. It should be noted that during all these activities,
head and neck should be straight, shoulders should be in line, abdominal
and gluteal muscles contracted for posterior pelvic tilts, and weight bearing
should be equal on both the lower limbs (Figure 12.47B). Mini or half squats
can be performed with the ball in the hand which improves the muscle control
of the entire body.
Dynamic tasks such as catching or kicking a ball challenge balance and
include the added challenge of anticipatory timing. These tasks also redirect
the patient’s attention to a task at hand rather than on balance itself, thus
testing the automaticity of postural responses. The patient can bounce the
ball on the ground and catch it with both the hands which elicits a response
of wrist and fingers extension. If during initial stages or due to spasticity,
patient is unable to open up the fingers, the therapist assists the affected side
wrist and fingers extension.
It can be noted from Figures 12.48A and B that the affected side is the
right side. Even with partial amount of motor control, the patient can perform
this task with concentration.
Ball catching activity in standing is an enjoyable activity for the patient,
which trains eye-hand coordination, upper limb motor control, bilateral activities
of upper limbs, and dynamic balance reactions in functional manner. The therapist
can make this activity challenging by throwing the ball at different speeds
and in different directions and asking the patient to catch it (Figure 12.49).
Standing position provides dynamic posture for many of the upper limb
A B
FIGURES 12.48A and B: Bouncing a ball and catching it, right hemiplegia
FIGURE 12.49: Catching a ball, left hemiplegia
A B
FIGURES 12.50A and B: Grasping objects with both hands at various angles,
right hemiplegia
tasks. Figures 12.50A and B shows the training of bilaterally symmetrical

upper limb activities which involve holding of objects at various levels of
upper limbs. Note the difference between the two Figures, where in one, the
hands of the patient are pronated while in other, they are supinated. These
activities can also be carried out while the patient is walking, which adds
A B
FIGURES 12.51A and B: (A) Walking forwards while beating a drum and (B) walking
backwards while beating a drum, right hemiplegia
B C
FIGURES 12.52A to C: Various hand functions in standing position
a dynamic component to the task and makes it difficult. Catching the ball,
tapping the ball on the ground and catching it, beating a drum (Figure 12.51),
or clapping while walking are all highly interesting tasks for the patient to
perform and increase the skill of movement.
Hand functions to improve dexterity of the fingers can be performed while
the patient is in standing position. Figures 12.52A to C show the patient
performing hand functions with the affected left hand. Note the associated
reaction which can be seen in the sound right upper limb.
FIGURE 12.53: Arranging playing cards, FIGURE 12.54: Hand functions in a group
left hemiplegia
A B C D
FIGURES 12.55A to D: Dressing up independently, right hemiplegia
Figure 12.53 shows the left-sided hemiplegic patient, arranging playing cards
with right hand in standing position. Arranging playing cards numberwise,
colorwise or patternwise will train sensory perception. Doing various activities
in standing position takes the attention away from the act of standing and
yet the patient has to maintain the postural balance in a subconscious way.
This activity thus prepares the patient to face the normal environment where
standing and walking is a basic need for carrying out various functional activities.
As shown above, guiding may be required in carrying out complex activities
of the hand in absence of adequate motor control. Usually, patient may be
able to pick up an object actively, while during release of the object, the
therapist guides by either opening up the fingers or adjusting the position
of the wrist passively (Figures 12.53 and 12.54).
As the recovery progresses, the patient is taught to do the day-to-day tasks
independently like the one showed above, dressing up (Figures 12.55A to
D). Other functional activities are practiced till the efficiency of the same
is increased. The time taken up for the functional activity is calculated and
patient tries to minimize the time consumed for the activity with the higher
precision level.
OBSTACLE WALKING
Walking in the normal environmental circumstances require negotiating various
hurdles and obstacles, especially in our country. Training of obstacle walking
in a clinical set up requires simple tools like a small board to cross over,
some stools to go around, a mat to train walking on a soft surface, low height
stool to climb on and get down, marked tiles for coordinated steps, etc. Adequate
support to the patient is given before the patient can actively negotiate the
obstacles. Figures 12.56A and B shows the cross over activity done by a
child.
Figure 12.57 shows a young boy with left-sided hemiplegia playing cricket
in the clinical set up. On carrying out the activity of choice, motor response
A B
FIGURES 12.56A and B: Crossover walking independently
FIGURE 12.57: Playing cricket, left hemiplegia

throughout the body is of the best quality. It also promotes sensory awareness,
sequencing of the movements and problem solving. All the patients of various
age groups are encouraged to play or carry out activity of their choice, as
soon as the physical condition allows.
STRENGTHENING EXERCISES USING

RESISTIVE TUBING
Use of a tubing of various resistance levels can be useful for strengthening
of the muscles. Although manual resistance provided by the therapist is best
in cases of hemiplegia, the tubing or the elastic bands give an ease of application
and the patient can perform these activities as a part of home program also
once they have mastered it.
A B
FIGURE 12.58: Resisted FIGURES 12.59A and B: Bilateral shoulder flexion
triceps workout using a strengthening using tubing, left hemiplegia
tubing, left hemiplegia
A B
FIGURES 12.60A and B: Bilateral shoulder abduction strengthening using tubing,
left hemiplegia
Figure 12.58 shows the resisted workout for

triceps muscle on affected left side.
Figures 12.59A and B show the resisted
workout of shoulder flexors on both the sides.
Figures 12.60A and B show the resisted
workout of shoulder abductors on both the sides.
Figure 12.61 shows resisted workout for a
combination of the movements of shoulder
flexion, abduction and horizontal abduction on
both sides.
In all the above Figures, note that the therapist FIGURE 12.61: Strengthening
guides and supports the movements wherever shoulder flexion and abduction,
with the use of tubing, left
needed. Similarly, resisted activities of many hemiplegia
other movements of upper limb, lower limb and
the trunk can be performed using an exercise
tubing or an elastic band. All these bands and tubings are available in different
resistance levels, and an adequate and optimum one is selected for the patient.
Recoil of the elastic material is faster and harder as the resistance level increases
and hence, the patient is asked to carry out the exercise smoothly and while
returning to the starting position, enough control is maintained.
List of the Muscles which can be Strengthened by

Tubing or Elastic Bands Easily
The following is the list of the muscles which can be easily strengthened
by the use of elastic bands and tubings. The best position in which this can
be achieved is also listed. It is understood that the practicing therapist can
modify the position according to the circumstances and needs of the patient.
 Serratus anterior
– Sitting, standing
 Trapezius upper, middle, lower
– Prone-lying, sitting, standing
 Latissimus dorsi
 Subscapularis
– Side-lying, sitting, standing
 Infraspinatus
 Supraspinatus
– Standing
 Teres major and minor

 Rhomboids major and minor
 Pectoralis major and minor
– Supine-lying, sitting, standing
 Deltoid—all fibers
– Supine-lying, side-lying, sitting, standing
 Biceps, brachialis, brachioradialis
 Triceps
 Long flexors of wrist and fingers
– Sitting
 Long extensor of wrist and fingers
– Sitting
 Abdominals including the obliques
 Iliacus and psoas major
 Gluteus maximus
– Prone-lying, supine lying, standing
 Gluteus medius
– Supine-lying, standing
 Adductor magnus, longus and brevis
– Supine-lying, standing
 Hamstrings
 Quadriceps
 Gastrocnemius and soleus
– Half-lying, long sitting, sitting
 Peroneus longus and brevis
– Half-lying, long sitting
 Tibialis anterior and posterior
– Half-lying, long sitting.
ADVANCED FUNCTIONAL TRAINING

Functional walking in the external environment effectively boosts up the
confidence of the patient. The patient can be taught to drive the vehicle which
is feasible. Gradually, all the activities are trained by the therapist and should
be practiced well by the patient to achieve functional independence.
To increase the muscle strength after the spasticity has significantly reduced
and motor function has improved, gymnasium activities can be started (Figures
12.62 and 12.63). Care should be taken not to overdo the exercises as they
can increase spasticity and can produce injury. These activities are always
carried out under strict supervision of a physiotherapist. Swimming can be
started as it is a wholesome exercise. It is easier if the patient had already
learned swimming in premorbid state. Learning swimming after hemiplegia
can be a challenging task. Nevertheless, it can be learned and practiced safely
in a controlled environment like shallow water.
FIGURE 12.62: Gym activities, right FIGURE 12.63: Gym activity for increasing
hemiplegia strength, right hemiplegia
FIGURE 12.64: Driving a car, right hemiplegia FIGURE 12.65: The normal walk,
at last!!!
Advanced functional activities like walking on the road and driving (Figures
12.64 and 12.65) can make the patient totally independent and confident for
facing the newer challenges posed by the life.
GROUP THERAPY
Hemiplegic patients require prolonged rehabilitation program in most of
the cases. Patients go to the physiotherapy and rehabilitation clinics for
a long period of time, daily. The exercise sessions may become routine
and boring, especially in the chronic phase because of the time taken for
the recovery. Many a times, a small amount of improvement will take
as long as few months. In such a case, the patients need to interact with
other patients to boost the morale and prepare for the time ahead. If the
patients of similar recovery are arranged in a group therapy session, all
the patients will enjoy the therapy session and the interaction with each
other will make the patient fell that they are not alone. In the group, there
will be a sense of healthy competition amongst the patients and the patients
will try to do their best.
Functional activities and the activities of daily living are best done in a
group. The physiotherapist’s time will be saved as the patients will monitor
each other’s progress with zeal and enthusiasm. Patients may play a game
or a two during such a session, which will ease out the stress and improve
the interpersonal relationships. They make newer friends and the sense of
isolation and the fear of nonacceptance in the society will decrease tremendously.
The patient will become punctual as the group has to meet at a fixed time
and this will stress the importance of time and scheduling in the patient who
is physically differently-abled for a long time. The more disabled patients
will get help from the more active members and thus, the activities which
are designed become easy for each member.
Therefore, the group has a very positive effect on the psyche of the patient
and is proved long before that such patients recover faster than the
conventionally treated patients in isolation. The group can be formed by
the physiotherapist and for forming the group, help from the patients who
are coming for a longer duration can be taken. The group can meet in the
clinic once a week or as designed by the physiotherapist. Group therapy
is valuable tool in the treatment of the patient and should be used extensively
but, judiciously for each patient attending the clinic. Even the home visit
patients can be called for the group session once a week, as it may not
be difficult to bring in the immobile patient in the wheelchair. The patients,
who may not be fit for the group, may be the patients who are very old
and severely osteoporotic, patients with severe psychiatric problems and
patients with active infective disease.
C H A P T E R
13
Proprioceptive Neuromuscular
Facilitation (PNF) Activities
Proprioceptive neuromuscular facilitation (PNF) activities are extremely useful

in treatment of hemiplegia. There are many methods of application by which
desired results can be achieved. Some of the very useful techniques are described
here.
FLEXION—ABDUCTION—EXTERNAL ROTATION
A B
FIGURES 13.1A and B
Joint Movement Muscles: Principal components

Scapula Posterior elevation Trapezius, levator scapulae,
serratus anterior
Shoulder Flexion, abduction, Anterior deltoid, long head of biceps,
external rotation coracobrachialis, supraspinatus,
infraspinatus, teres minor
Elbow Extended—position Triceps, anconeus
unchanged
Proprioceptive Neuromuscular Facilitation (PNF) Activities 299
Forearm Supination Biceps, brachioradialis, supinator

Wrist Radial extension Extensor carpi radialis—longus
and bravis
Fingers Extension, radial Extensor digitorum longus,
deviation interossei
Thumb Extension, abduction Extensor pollicis—longus and
brevis, abductor pollicis longus
WITH ELBOW EXTENSION
A B
FIGURES 13.2A and B
Joint Movement Muscles : Principal components

Scapula Posterior elevation Trapezius, levator scapulae,
serratus anterior
Shoulder Flexion, abduction, Anterior deltoid, long head
external rotation biceps, coracobrachialis,
supraspinatus, infraspinatus,
teres minor
Elbow Extension Triceps, anconeus
Forearm Supination Biceps, brachioradialis, supinator
Wrist Radial extension Extensor digirorum longus,
interossei
Fingers Extension, radial Extensor digitorum longus,
deviation interossei
Thumb Extension, abduction Extensor pollicis—longus and
brevis, abductor pollicis longus
FLEXION—ADDUCTION—EXTERNAL ROTATION
WITH ELBOW FLEXION
A B
FIGURES 13.3A and B

Scapula Anterior elevation Upper Serratus anterior,
trapezius
Shoulder Flexion, adduction, Upper pectoralis major, anterior
external rotation deltoid, biceps, coracobrachialis
Elbow Flexion Biceps, brachialis
Forearm Supination Brachioradialis, supinator
Wrist Radial flexion Flexor carpi radialis
Fingers Flexion, radial deviation Flexor digitorum superficialis
and profundus, lumbricales,
interossei
Thumb Flexion, adduction Flexor pollicis longus and brevis,
adductor pollicis
WITH ELBOW EXTENSION
A B
FIGURES 13.4A and B

Scapula Anterior elevation Upper serratus anterior,
trapezius
Shoulder Flexion, adduction, Upper pectoralis major, anterior
external rotation deltoid, biceps, coracobrachialis
Elbow Extension Triceps, acnoneus
Forearm Supination Brachioradialis, supinator
Wrist Radial flexion Flexor carpi radialis
Fingers Flexion, radial deviation Flexor digitorum superficialis
and profundus, lumbricales,
interossei
Thumb Flexion, adduction Flexor pollicis longus and brevis,
adductor pollicis
EXTENSION—ABDUCTION—INTERNAL
ROTATION WITH ELBOW EXTENSION
A B
FIGURES 13.5A and B

Scapula Posterior depression Rhomboids
Shoulder Extension, abduction, Latissimus dorsi, deltoid—
internal rotation middle and posterior, triceps,
teres major, subscapularis
Elbow Extension Triceps, acnoneus
Forearm Pronation Brachioradialis, pronator teres
and quadratus
Wrist Ulnar extension Extensor carpi ulnaris
Fingers Extension, ulnar Extensor digitorum longus,
deviation lumbricales, interossei
Thumb Palmar abduction, Abductor pollicis brevis, extensor
extension pollicis
BILATERAL SYMMETRICAL: FLEXION—

ABDUCTION—EXTERNAL ROTATION
A B
FIGURES 13.6A and B
These movements train upper limbs in a bilaterally symmetrical pattern. The

sound upper limb movements reinforce the movements on affected side. These
activities are useful in initial stages when motor control is developing.
BILATERAL ASYMMETRICAL: FLEXION—

ABDUCTION—EXTERNAL ROTATION WITH THE
RIGHT ARM; FLEXION—ADDUCTION—
EXTERNAL ROTATION WITH THE LEFT ARM
A B
FIGURES 13.7A and B
These movements train upper limbs in bilaterally asymmetrical pattern. They are
useful in later stages of recovery to dissociate one limb movements from other.
AT END RANGES, LYING PRONE ON ELBOWS
FIGURE 13.8
These activities train weight-bearing on affected side in prone, movements

of upper extremity in prone and end range shoulder and scapular motion.
FLEXION—ABDUCTION—INTERNAL ROTATION
A B
FIGURES 13.9A and B

Hip Flexion, abduction, Tensor fascia lata, rectus femoris,
internal rotation gluteus medius—anterior,
gluteus minimus
Knee Extended—position Quadriceps
unchanged
Ankle/foot Dorsiflexion, eversion Peroneus tertius
Toes Extension, lateral Extensor hallucis, extensor
deviation digitorum
WITH KNEE FLEXION
A B
FIGURES 13.10A and B

internal rotation gluteus medius—anterior,
gluteus minimus
Knee Flexion Hamstrings, gracilis,
gastrocnemius
deviation digitorum
WITH KNEE EXTENSION
A B

internal rotation gluteus medius—anterior
gluteus minimus
Knee Extension Quadriceps

deviation digitorum
EXTENSION—ADDUCTION—EXTERNAL
ROTATION
A B

Hip Extension, adduction, Adductor magnus, gluteus
external rotation maximus, hamstrings, lataral
rotators
Knee Extension—position Quadriceps
unchanged
Ankle Plantar flexion, inversion Gastrocnemius, soleus, tibialis
posterior
Toes Flexion, medial deviation Flexor hallucis, flexor digitorum
WITH KNEE FLEXION
A B

Hip Flexion, adduction, Psoas major, iliacus, adductor
external rotation muscles, sartorius, pectineus,
rectus femoris
Knee Flexion Hamstrings, gracilis,
gastrocnemius
Ankle/foot Dorsiflexion, inversion Tibialis anterior
Toes Extension, medial Extensor hallucis, extensor
deviation digitorum
WITH KNEE EXTENSION
A B

Hip Flexion, adduction, Psoas major, iliacus, adductor
external rotation muscles, sartorius, pectineus,
rectus femoris
Knee Extension Quadriceps
Ankle/foot Dorsiflexion, inversion Tibialis anterior
Toes Extension, medial Extensor hallucis, extensor
deviation digitorum
ROTATION
A B

Hip Extension, abduction, Gluteus medius, gluteus
internal rotation maximus—upper hamstrings
Knee Extended—position Quadriceps
unchanged
Ankle/foot Plantar flexion, eversion Gastrocnemius, soleus, peroneus
longus and brevis
Toes Flexion, lateral deviation Flexor hallucis, flexor digitorum
ROTATION WITH KNEE EXTENSION
A B

internal rotation maximus—upper hamstrings
Knee Extended Quadriceps
Ankle/foot Plantar flexion, eversion Gastrocnemius, soleus, peroneus
longus and brevis
ROTATION WITH KNEE FLEXION
A B

internal rotation maximus—upper
Knee Flexion Hamstrings, gracilis
Ankle Plantar flexion, eversion Soleus, peroneus longus and brevis
BILATERAL SYMMETRICAL LEG PATTERNS:

FLEXION—ABDUCTION WITH KNEE EXTENSION
IN SITTING
A B
These activities train lower limbs in a bilateral symmetrical pattern of activity.

Mirroring of the movements on the affected side helps in irradiation.
BILATERAL ASYMMETRICAL PATTERNS:

FLEXION—ABDUCTION WITH KNEE EXTENSION
ON THE LEFT; EXTENSION—ABDUCTION WITH
KNEE FLEXION ON THE RIGHT
A B
These activities train lower limbs in bilateral asymmetrical pattern of activity

and helps in dissociation of mass movement patterns. It is useful in gait training.
BILATERAL SYMMETRICAL PATTERN IN

SUPINE—FLEXION—ABDUCTION
A B
LEG PATTERNS IN SITTING: EXTENSION—

ADDUCTION WITH KNEE FLEXION
A B
This activity trains knee extension with dorsiflexion of ankle and knee flexion
with planter flexion of ankle. It is useful in walking. Note the position of
the hip too.
LEG PATTERNS IN SITTING: EXTENSION—

ABDUCTION WITH KNEE FLEXION
A B
FLEXION—ADDUCTION WITH KNEE EXTENSION
A B
PATTERNS OF TRUNK
Chopping in Lying
A B
Figures 13.24A and B: Chopping from the left to the right with trunk flexion in
lying
Chopping in Sitting
A B
Figures 13.25A and B: Chopping from the left to the right with trunk flexion in
sitting
BILATERAL LEG PATTERNS FOR TRUNK IN LYING
A B
Figures 13.26A and B: Bilateral hip-knee flexion with flexion and rotation of
trunk from left to the right side
BILATERAL LEG PATTERNS FOR TRUNK IN

SITTING
A B
Figures 13.27A and B: Bilateral hip-knee flexion with flexion and rotation of
trunk from left to right side in sitting
COMBINING PATTERNS FOR THE TRUNK
A B
Figures 13.28A and B: Combination of hip-knee flexion with lower trunk
flexion and rotation to the left with upper trunk rotation to the right side in
lying
RESISTIVE PATTERNS ON MAT
A B
Figures 13.29A and B: Taking prone on elbows, right hemiplegia
A B
Figures 13.30A and B: Resisting upper trunk extension
Note; Similar resistance can also be applied to pelvis when the patient tries
to come on all fours. The resistance provides facilitation to the contracting
muscles and hence, quality of movement improves along with the strength
C H A P T E R
14
Orofacial Rehabilitation
RESPIRATORY AND OROMOTOR ACTIVITIES

Goals of early training include normalizing respiratory, facial, swallowing,
and chewing functions. Patients on prolonged bed rest with marked
deconditioning, marked paralysis, or dysarthria may experience impaired or
shallow breathing patterns. Improved chest expansion can be achieved by
effective use of manual contacts, resistance, and stretch to various chest wall
segments. Diaphragmatic, basal and lateral costal expansion should be stressed.
A pre-speech activity consists of having the patient maintain a vocal expression
(e.g.; “ah”) during the entire expiratory phase, since poor breath control often
contributes to soft or vacillating production of sounds. Respiratory activities
should be combined with other movement patterns whenever possible (e.g.
inspirations with PNF reverse chop pattern and expiration with chop). During
any sustained activity (isometric holding), breath control should be emphasized;
the valsalva maneuver should always be avoided. This is especially important
in stroke patients with documented concomitant cardiovascular problems.
Facial movements should be encouraged and facilitated whenever necessary.
This may include the use of stretch, resistance, or quick ice to stimulate the
desired function. Emphasis should be placed on the affected muscles in order
to regain a balance of function. The use of a mirror may be helpful in treatment,
providing the patient does not have visuospatial dysfunction.
The goals of oromotor retraining are: to improve strength, coordination,
and range of oral musculature, to promote normal feeding through graduated
resumption of activities, and to promote volitional control through effective
verbal coaching. A key element is the attainment of an upright sitting posture
with hips well back, symmetrical weight-bearing, and feet flat on the floor.
Orofacial Rehabilitation 315
The head should be erect and in its normal position rather than extended
or tipped back. This reduces the chances of aspiration or choking and promotes
normal swallowing through appropriate alignment of the necessary structures.
If the patient lacks adequate head control, the head should be supported either
manually or with supports. Food should be positioned at an appropriate height
and distance from the patient and in the patient’s visual field. Adapted utensils,
plate guards, and non-slip mats can be used to assist in the transfer of food
to the mouth. Food should be at first semi-moist, progressing to foods rich
in taste, smell and texture, qualities which assist in facilitating the swallowing
reflex. Sensation, reflex activity (gag), and breath control are necessary.
Facilitation techniques can be used to stimulate the muscles responsible for
jaw opening and closing. Jaw movements can be stimulated by vibrating or
pressing above the upper lip for closure and under the lower lip for opening.
Jaw closure can also be assisted, when necessary, during feeding by holding
the jaw firmly closed, using a jaw control technique. Tongue movements can
be resisted manually or with a moist tongue depressor. Firm pressure to the
anterior third of the tongue can be used to stimulate the posterior elevation
of the tongue, necessary for swallowing. Sucking control and saliva production
can be stimulated using small amounts of ice water or an ice cube. The therapist
can also apply deep pressure on the neck above the thyroid notch to stimulate
sucking. Resisted sucking can be promoted using a straw and very thick liquids,
or by holding the open end of the straw against the finger. As sucking control
proceeds, thinner liquids can be substituted. Patients with a hypoactive gag
reflex may be stimulated briefly with a cotton swab to develop this response.
An additional consideration for successful feeding includes management
of the environment. The patient’s full attention should be directed to the task
at hand by using appropriate and consistent verbal cues.
MUSCLES OF FACIAL EXPRESSIONS

While treating the facial muscles, use of the stretch reflex and resistance promotes
muscle activity and increases strength. Proper grip and pressure will guide
and facilitate the movements. Additional facilitation can be achieved by use
of ice. Two to three quick short strokes with ice on the skin, overlying the
muscles, on the tongue and inside the mouth facilitate movements. Use of
bilateral movements is advocated when exercising the face. Contraction of
muscles on the stronger or more mobile side will facilitate and reinforce the
action of weaker side. Timing for emphasis, by preventing full motion on
the stronger side, will further promote activity in the weaker muscles. The
muscles of the face have many functions including facial expressions, jaw
motion, protecting the eyes, aiding in speech and assisting in breathing.
The general principles in treatment of face include:
 Gross motions are mass opening and mass closing of mouth
 There are two general areas: The eyes and the forehead, the mouth and
the jaw. The nose works with both
 Facial motions are exercised in diagonal patterns
 Bilateral treatment is advocated
 Strong motions in other parts of the body reinforce facial movements. For
example, while doing heavy work with hands, facial expression changes
 A functional position is chosen for treating facial muscles
 A mirror can help in giving visual biofeedback.
Frontalis
Command: “Lift your eyebrows up,
look surprised, and wrinkle your
forehead.”
A B
Apply resistance to the forehead, FIGURES 14.1A and B: (A) PNF for
pushing caudally and medially. This frontalis, starting position and (B) PNF for
motion works with eye opening frontalis, end position
(Figure 14.1). It is reinforced with
neck extension.
Corrugator
Command: “Frown, pull your A B
eyebrows down.” FIGURES 14.2A and B: (A) PNF for
corrugator, starting position and (B) PNF
Give resistance just above the for corrugator, end position
eyebrows, diagonally in a cranial and
lateral direction (Figure 14.2). This
motion works with eye closing.
Orbicularis Occuli (Upper)

A B
Command: “Close your eyes.”
FIGURES 14.3A and B: (A) PNF for
Give gentle diagonal resistance to the orbicularis occuli-upper, starting position
upper eyelids. Avoid putting pressure and (B) PNF for orbicularis occuli–upper
end position
on the eyeballs (Figure 14.3).
Orbicularis Occuli (Lower)

Command: “Close your eyes.”
Give gentle diagonal resistance to the
lower eyelids (Figure 14.4). Again A B
avoid putting pressure on the eyeballs. FIGURES 14.4A and B: (A) PNF for
orbicularis occuli–lower, starting position
and (B) PNF for orbicularis occuli–lower
end position
Orbicularis Oris
Command: “Purse your lips, whistle,
say ‘prunes’.”
Give resistance laterally and upwards A B
to the upper lip, laterally and FIGURES 14.5A and B: (A) PNF for
downward to the lower lip (Figure orbicularis oris, starting position and (B)
PNF for orbicularis oris, end position
14.5).
Mentalis
Command: “Wrinkle your chin.” A B
Apply resistance down and out at the FIGURES 14.6A and B: (A) PNF for
chin (Figure 14.6). mentalis, starting position and (B) PNF for
mentalis, end position
Levator Labii Superioris

Command: “Lift your upper lip, show A B
your upper teeth.” FIGURES 14.7A and B: (A) PNF for levator
Apply resistance to the upper lip, labii superioris, starting position, and (B)
PNF for levator labii superioris, end position
downward and medially (Figure 14.7).
Levator Anguli Oris

Command: “Pull the corner of your
mouth up, a small smile.” A B
FIGURES 14.8A and B: (A) PNF for levator
Push down and in at the corner of anguli oris, starting position and (B) PNF
the mouth (Figure 14.8). for levator anguli oris, end position
Depressor Anguli Oris

Command: “Push the corners of your
mouth down, look sad.”
A B
Give resistance upwards and medially
to the corners of the mouth (Figure FIGURES 14.9A and B: (A) PNF for
depressor anguli oris, starting position and
14.9). (B) PNF for depressor anguli oris, end
position
Buccinator
Command: “Suck your cheeks in, pull
in against the tongue blade.”
A B
Apply resistance on the inner surface FIGURES 14.10A and B: (A) PNF for
of cheeks with your gloved fingers buccinator using a spoon, starting position
or a dampened tongue blade. The and (B) PNF for buccinator using a spoon,
end position
resistance can be given diagonally
upwards or diagonally downwards as
well as straight out (Figure 14.10).
Procerus
Command: “Wrinkle your nose.”
Apply resistance next to the nose
diagonally down and out (Figure
14.11).
This muscle works with corrugators
muscle and with eye closing. FIGURE 14.11: PNF for procerus
Zygomaticus Major
Command: “Smile.”
Apply resistance to the corners of the
mouth, medially and slightly
downward (Figure 14.12).
FIGURE 14.12: PNF for zygomaticus

major
The functional activities as in mouth opening, combination of muscle

contraction is required for achieving the desired motion. After carrying out
the diagonal pattern of individual muscle activity, muscles can be trained in
a group for some purposeful tasks. Smooth interplay of muscles is required
for the coordinated task and unwanted activity in other part of the face should
be inhibited by giving strong verbal commands and by visual biofeedback.
Initially, the therapist actively assists these movements on both the sides for
symmetry of motion. Gradually, only the affected side needs to be assisted
till the patient is able to actively achieve the movement. In day to day life,
individual contraction of facial muscle is rarely seen and almost always a
combination of different muscles is responsible for carrying out various tasks.
As the training progresses, unilateral activation of the facial movements on
either side, i.e. affected and unaffected both is carried out and various complex
expressions can be worked out upon with assistance from immediate family
and friends, if need be, to ensure similar expressiveness to that of the premorbid
state (Figure 14.13).
A B
FIGURES 14.13A and B: Combined movement pattern as in showing the teeth
STIMULATION OF LIPS AND ORAL CAVITY

(VIBRATION AND ICING)
Activities of chewing and swallowing
need to be trained right from the initial
stages. Even in patients with no apparent
facial involvement, there may be overall
decrease in tone of the muscles which
may lead to difficulty in swallowing and
controlling saliva in the oral cavity. FIGURE 14.14: Tooth brush with
Prolonged presence of a Ryle’s tube vibrator
A B
FIGURES 14.15A and B: (A) Vibrations on inside area of lips and (B) vibrations
on outside area of lips
inhibits sucking and swallowing reflexes. The protocol of oral rehabilitation

commences with sensory activation of the lips and oral cavity (Figures 14.14
and 14.15). Mechanoreceptors are activated with the use of vibratory sense.
The vibrations can be provided by a hand held ‘vibratory toothbrush’ available
easily in the market.
The vibrator is moved gently on the outer surface of the lips. Gradually,
it is also moved on the inner surface of both the lips with mouth kept open.
A 50 Hz frequency can be selected initially moving on to 100 Hz, if option
is available. The second step of treatment is to apply vibrations in the entire
oral cavity (Figure 14.16).
A B
FIGURES 14.16A and B: Vibrations in the oral cavity
These techniques improve sensitivity of

the oral cavity, reduce dribbling of saliva
and improve the tone of lips and buccal
cavity. Vibratory stimulation can also be
used in improving sensitivity and tone and
hence, the movements of the tongue. The
vibrator can be moved on the entire tongue
but care should be taken as stimulating
the posterior area of the tongue may induce
an exaggerated gag (Figure 14.17). FIGURE 14.17: Vibrations on the
The vibrations applied over the tongue tongue
A B C
FIGURES 14.18A to C: (A) Icing over the lips, (B) icing on the tongue and (C)
icing for facial muscles
are also effective in normalizing the tone of spastic tongue along with icing
and passive stretching of the tongue.
Icing of the lips, oral cavity and the tongue has proved to be highly effective
in improving the functions. Ice is applied over the lips, inside surface of
the lips, inside the oral cavity and on the tongue (Figure 14.18). Quick ice
facilitates the movements while, the prolonged ice is useful in reducing the
tone of spastic tongue.
RESISTED TONGUE MOVEMENTS

Tongue is a muscle which has only one attachment, other side is free for
movement and articulation with various parts of the oral cavity for production
of different sounds. Twisting motion of the tongue prepares bolus of the food
and its wave-like motion pushes the bolus near the esophagus. Weakness or
spasticity in the tongue may produce difficulty in speech and difficulty in
swallowing. Active exercises for the tongue help in normalizing the above
mentioned functions.
Active exercises for the tongue are:
 Protrusion
 Taking tongue back
 Taking tip of the tongue to the right
 Taking tip of the tongue to the left
 Rotating the tongue in oral cavity
 Rolling the tongue up on the upper rows of teeth
 Rolling the tongue on the lower rows of teeth
 Making a ‘U’ shape with tongue as if a narrow tunnel
 Twisting the tongue
Majority of the tongue movements can be resisted to facilitate the functions.
A use of a blunt spoon or a spatula is advised.
Upward motion is resisted by keeping the spoon on the distal part of tongue
and pressing down, while the patient attempts to take the tongue up (Figure
14.19A). Side to side motions and protrusion can also be resisted by applying
A B
C D
FIGURES 14.19A to D: (A) Resisted upward movements of tongue, (B) resisted
left sided movements of tongue, (C) resisted right sided movements of tongue
and (D) resisted protrusion of tongue
resistance in proper directions (Figures 14.19B to C). Backward movement

of the tongue can be resisted by asking the patient to first protrude the tongue
out of the mouth. Then, the tongue can be held by a sterile gauze with gloved
fingers of the therapist. The patient then attempts to take the tongue back
while the therapist applies resistance.
CHEWING AND DEGLUTITION

Chewing can be facilitated early by asking the
patient to chew semi-hard substances like an apple
or a carrot. Placing such food articles themselves
facilitates the chewing action (Figure 14.20).
Cutting and tearing can be practiced by the incisors
(teeth in front) while grinding can be practiced
by the premolars and the molars (teeth at the side
and back).
All the activities of the tongue and chewing
are carried out while the patient is in sitting position FIGURE 14.20: Chewing a
with the head kept erect. Facilitation of chewing juicy apple
can be carried out as described below.
A B
FIGURES 14.21A and B: Grip for facilitation of chewing and deglutition
The patient is sitting straight with adequate support. The head is supported
by the therapist who is standing sideways and behind the patient. The therapist
controls the movement of the head of the patient with left hand while the
right hand is placed on the patient’s jaws as shown in Figures 14.21A and
B. The thumb is placed on the temporomandibular joint and index finger
controls the opening and closing of the mouth and lower lip. Middle and
ring fingers are kept on under surface of the chin on the mylohyoid muscle.
Wave-like motion of the tongue in backward direction and contraction of the
muscle of the floor of the mouth—mylohyoid whose action is to contract
the floor of the mouth; is facilitated by applying a firm and gentle pressure
in up and backward direction towards the esophagus while the mouth is closed.
This movement is carried out initially with nothing in mouth except saliva
and progression is made by introducing food articles of different sizes and
textures.
ACTIVITIES FOR COORDINATION OF

EYE MOVEMENTS
Activities which train eyeballs and which improve field of vision are started
as and when required. Following an object only with the eyes without moving
the head and neck, is started in the initial stages.
 The therapist holds a brightly colored object in front of the patient who
is seated comfortably with the head and neck held straight. The therapist
asks the patient to look to the object and keep the vision fixed. The therapist
moves the object in various directions and asks the patient to look at it,
without moving the head and the neck.
– The therapist moves the object upward and hence, the patient has to
move the eyeballs upwards to look at it (Figure 14.22).
A B
FIGURES 14.22A and B: Following an object with eyes upwards. neck is not moved
– The therapist moves the object downwards and hence, the patient has
to move the eyeballs downwards to look at it (Figure 14.23).
FIGURE 14.23: Following an object with eyes

downwards
– The therapist moves the object to the right and to the left and hence,
the patient has to move the eyeballs to the right and to the left, respectively
(Figures 14.24A and B).
A B
FIGURES 14.24A and B: Following an object with eyes side-to-side
– The therapist moves the object diagonally upwards and to the right and
downwards to the left, and hence, the patient has to move the eyeballs
accordingly upwards to the right and downwards to the left (Figures
14.25A and B).
A B
FIGURES 14.25A to D: Following an

object with eyes-diagonally on either
side: (A) up and to the right, (B) down
and to the left, (C) up and to the
left and (D) down and to the right
C D
– The therapist then moves the object diagonally upwards to the left and
downwards to the right and hence, the patient moves the eyeballs
accordingly upwards to the left and downwards to the right (Figures
14.25C and D).
 In another method, the
therapist keeps the object
immobile while the patient
moves the head in various
directions all the while
looking at the stationary A B
object. The neck is moved
upwards, downwards, to the
right and to the left, as
shown in Figures 14.26A to
D. Diagonal patterns can
also be added later on as FIGURES 14.26A to D: Moving the head while
a progression to this activity. constantly looking at an object (eyes fixed
 A beautiful smile is what the on the moving object): (A and B) up-down and
(C and D) side-to-side
patients and their therapists
work for isn’t it? As shown
in the Figure 14.27, proper
smile will increase the
confidence of the patient
and one will feel confident
to confront upcoming social
interactions.
FIGURE 14.27: A beautiful

smile at last
C H A P T E R
15
Perceptual Dysfunctions and
Treatment
SOMATOSENSORY DYSFUNCTION
It includes disorder of sensation and perception.
Sensation: It refers to the activity from the peripheral sensory receptors, primary
afferent sensory tracts and the appropriate 1° sensory cortex.
Perception: It refers to the integration of sensory impressions into
psychologically meaningful information, i.e. it is a processing in the brain
that transforms all the information from visual, auditory, tactile and kinesthetic
channel into our immediate experiences of the world.
It is sometimes difficult to differentiate between the two:
 Sensation when impaired causes distortion of information from self and
the environment.
 Perception when impaired causes dysfunction in understanding and
interpreting information from self and from the environment.
Common Dysfunctions
 Impaired proprioception
 Impaired tactile sensation
 Astereognosis
 Asomatognosia.
Impaired Proprioception
– Difficulty in maintaining balance
– Appears to forget affected body parts
– Joint damage
– Asymmetrical posture.
Perceptual Dysfunctions and Treatment 327
Impaired tactile sensation:

– It affects motor activity, as sensory feedback is limited
– Functional perception is impaired
– Damage of affected part, particularly to skin breakdown resulting in
bedsores
– Lack of awareness of body parts.
Astereognosis
– Astereognosis is defined as the inability to recognize the form and nature
of common objects without looking at it. Integration of various sensory
modalities is required.
Asomatognosia
– It is loss of knowledge and awareness of one’s own body and position
of the body and its parts in relation to themselves and objects in the
environment.
Related deficits include:
– Right/left discrimination problem
– Impaired body part identification
– Finger agnosia
– Anosognosia (denial of one’s illness)
– Unilateral neglect.
Unilateral neglect
– It is manifested by a failure to respond to or orient to stimuli presented
contralateral to brain lesion
– It is commonly seen in (left) hemiplegics
– It is frequently seen in combination with visual field deficits
– Bizarre statements about limb found in unexpected places
– Naming the affected part
– ‘Alien hand syndrome.’
Functional corelation
– Shaves only one side of his face
– Reading is also impaired
– Writing only on one side of paper.
PERCEPTUAL DISABILITIES:
SITE AND SIDE OF LESION
See Table 15.1.
TABLE Site and side of lesion and perception deficits

15.1
Local vascular Left hemisphere Right hemisphere deficits
supply deficits (dominant) (non-domimant)
Temporal lobe Somatoagnosia Unilateral neglect
Internal carotid artery Auditory agnosia Constructional apraxia
Posterior cerebral artery Ideomotor apraxia Difficulty recognizing
Middle cerebral artery Ideational apraxia complex or incomplete
Constructional apraxia visual stimuli
Disorders of speech
Acalculia
Occipital lobe Visual object agnosia Visual object agnosia
Posterior cerebral artery Simultagnosia Color agnosia
Prosopagnosia Topographical
Color agnosia disorientation
Constructional apraxia Depth and distance
Right homonymous perception
hemianopsia Prosopagnosia
Sensory aphasia Dressing apraxia
Alexia Left homonymous
Agraphia hemianopsia
Acalculia Symbol agnosia
Complex visual
hallucinations
Parietal lobe Somatagnosia Unilateral neglect
Internal carotid artery Right-left discrimination Right-left discrimination
Anterior cerebral artery Finger agnosia Finger agnosia
Posterior cerebral artery Gerstmann’s syndrome Anosognosia
Middle cerebral artery Visual object agnosia Spatial relations syndrome
Visual spatial agnosia Figure-ground discrimination
Astereognosis Form constancy
Ideomotor apraxia Position in space
Ideational apraxia Topographic disorientation
Constructional apraxia Vertical disorientation
Aphasia Visual object agnosia
Alexia Visual spatial agnosia
Agraphia Astereognosis
Acalculia Dressing apraxia
Diminished logic Difficulty comprehending the
emotional tone of
language
Frontal lobe Motor aphasia Motor amusia

Internal carotid artery Agraphia Motor apraxia
Middle cerebral artery Verbal apraxia
Anterior cerebral artery Motor apraxia
BODY SCHEME AND BODY IMAGE DISORDERS

Body image is defined as a visual and mental image of one’s body that includes
feelings about one’s body, especially in relation to health and disease. The
term body scheme refers to a postural model of the body, including the
relationship of the body parts to each other and the relationship of the body
to the environment. Body awareness is derived from the integration of tactile,
proprioceptive and interoceptive sensations, in addition to the individual’s
subjective feelings about the body. An awareness of body scheme is considered
one of the essential foundations for the performance of all purposeful motor
behavior. The two terms, body image and body scheme, are often used
interchangeably. Specific disturbances of body image and body scheme are
somatagnosia, visual or unilateral spatial neglect, right-left discrimination, finger
agnosia and anosognosia.
Somatagnosia
Somatagnosia, or impairment in body scheme, is a lack of awareness of the
body structure and the relationship of body parts in oneself or in others. Patients
with this deficit may display difficulty following instructions that require
distinguishing body parts and may be unable to imitate movements of the
therapist. Often patients report that the affected arm or leg feels unduly heavy.
Lack of proprioception may underlie or compound this disorder. Body scheme
impairment is also termed autopagnosia.
Clinically, the patient may have difficulty performing transfer activities
because he or she does not perceive the meaning of terms related to body
parts, for example, “pivot on your leg and reach for the armrest with your
hand”. Additionally, a patient with a body scheme disorder will have difficulty
in dressing up. Patients may have a hard time participating in exercises that
require some body parts to be moved in relation to other body parts; for
example, “bring your arm across your chest and touch your shoulder.
The lesion site is the dominant parietal lobe, or posterior temporal lobe.
Thus, this disorder is seen primarily with right hemiplegia. However, impairment
in body scheme may also occur with left hemiplegia.
Assessment
 The patient is requested to point to body parts named by the therapist,
on himself or herself, on the therapist, and on a picture or puzzle of a
human Figure. For example, “show me your feet. Show me your chin.
Point your back.” The words “right” and “left” should not be used because
they may lead to an inaccurate diagnosis with right-left discrimination. Aphasia

should be ruled out as a cause of poor performance.
 The patient is asked to imitate movements of the therapist. For example,
the therapist touches his or her cheek, arm, leg, and so forth. A mirror-
image response is acceptable.
 The patient is requested to answer questions about the relationship of body
parts. For example, “are your knees below your head?” which is on top
of your head, your hair or your feet?” for patients with aphasia, questions
should be phrased to require a yes or no or true or false response. Patients
with intact function in this area should respond correctly most of the time
and within a reasonable period of time. Those patients with receptive aphasia
are particularly likely to do poorly on tests for somatagnosia.
Treatment
 The sensorimotor approach attempts to associate sensory input with an
adaptive motor response. Facilitation of body awareness is accomplished
through sensory stimulation to the body part affected. For example, the
patient is asked to rub the appropriate body part with a rough cloth as
the therapist names it or points to it.
 With the transfer of training approach, the patient verbally identifies body
parts, or points to pictures of them as the therapist touches them.
UNILATERAL VISUAL OR SPATIAL NEGLECT

Homonymous Hemianopia
It is defined as loss of vision in one-half of the visual field following lesions
of the optic tract, the lateral geniculate nucleus or the visual cortex.
Functional Impairment
It decreases the patient’s awareness of the environment and affects the
performance of the motor task. Patient may demonstrate lack of appreciation
or the need to scan or turn their head to affected side unless prompted or
taught to do so. May bump into objects or be startled by their presence.
Visual Inattention
Lack of response to stimuli on the affected side when simultaneous stimuli
are applied to both sides and there is no actual visual field defect. Patient
will be able to see a visual stimulus placed on the side, contralateral to the
lesion, but fails to perceive it, when there are simultaneous bilateral stimuli.
Unilateral spatial neglect, sometimes termed visual hemi-inattention when

referring to the visual component, is the inability to register and to integrate
stimuli and perceptions from one side of the body and the environment. This
usually, although not always, affects the left side of the body, and for purposes
of this discussion, we still assume that it is the left. The patient ignores the
left side of the body and stimuli occurring in the left personal space. This
may occur despite intact visual fields, or concomitantly with right or left
homonymous hemianopsia; however, it is not caused by hemianopsia. Frequently,
the patient has sensory loss on the affected side, which compounds the problem.
Although, the patient with left-sided hemianopsia has actual loss of vision
from the left visual field of both eyes, he or she may be aware of the problem
and compensate by turning the head. The patient with visual neglect has intact
vision but seems unaware of the problem and does not attempt to compensate
spontaneously by turning the head. In extreme cases, the patient appears totally
indifferent to the left side of the body and environment, and may deny that
the left extremities belong to him or her. More time seems to be required
in learning to compensate for this disability than with hemianopsia. There
is great difficulty in integrating all stimuli from the left half of the body
and personal space for use in ADLs. As with hemianopsia, the patient with
visual spatial neglect often avoids crossing the midline visually or motorically.
Current theories consider spatial neglect a disturbance of attention. It is important
for the therapist to be familiar with this disorder as it is frequent clinical
finding following a right hemisphere stroke.
Clinically, the patient ignores the left half of the body when dressing and
forgets to put on the left sleeve or left pants leg. Often a male patient will
forget to shave the left half of his face. The patient may neglect to eat from
the left half of the plate and will start reading a newspaper from the middle
of the line. Typically, the patient bumps in to objects on the left side or tends
to veer towards the right when walking or propelling a wheelchair.
Assessment
 The patient is asked to copy simple drawings of a house, a tree, a person,
and/or a clock. The drawings done by a patient with this deficit will have
parts missing from the left half of the picture or be lacking in detail.
Differentiate these drawings from those likely to be produced by a patient
suffering from constructional apraxia, in which most parts would be present
but not in correct relation to each other. In addition, many patients with
constructional apraxia will improve when copying a model, but those with
unilateral neglect will not.
 The patient is asked to read aloud. It should be noted if words are missed
on the left half of the page or if there is hesitation at the beginning of
a line.
Approach
 Use stimuli that are specialized for the right side of the brain, such as
shapes and blocks, to enhance right brain activation.
 At the same time, minimize the presence of stimuli that are known to activate
the left side of the brain, such as letters and numbers.
 Minimize the use of verbal instructions. Keep stimuli simple. Combine this
with instructions to the patient to turn the head to the left, in order to
anchor his or her attention to that side of space.
 Cognitive compensation (based on Weinberg and co-workers): The patient
is taught to be aware of the deficit through the method of visual scanning.
This technique is used to help the patient become aware of the imbalance
in perception of the two sides of space. The patient practices turning toward
the left and shifting the eyes to the left. With experience, the patient will
begin to trust visual cues to guide action. For example, a patient does
not shave properly on his left side. When asked to touch both sides of
his face, or to look in the mirror, he will not notice that anything is amiss.
However, after being trained to systemically scan the visual environment,
starting with the left side of his face, the patient may notice the unshaven
side in the mirror. At a later date, when asked to touch both sides of his
face, he will confirm that one side is unshaven and take appropriate action.
 Using the functional approach, repeated practice is used in particular areas
of difficulty in ADLS, such as transferring from a wheel chair or eating.
Visuospatial deficits may interfere extensively with performance of ADLs.
 The following steps are recommended by Stanton and associates: Break
down the activity in to small components. Have the patient practice each
one in sequence until a criterion level has been reached; then taper the
cues. Finally, arrange the activity in to larger components. Keeping ongoing
records of progress will assist the therapist in guiding treatment appropriately.
Encourage verbal self-cuing in verbally intact patients.
Adapting the Environment

 The patient is addressed and given demonstrations from the unaffected side.
The nursing staff should place the patient’s call button, telephone, and other
essential paraphernalia on the unaffected side. A bold red line is drawn
on the side of the page that is neglected. A mirror may be placed in front
of the patient while he or she is dressing or ambulating to draw attention
to the neglected side.
 Using the sensorimotor approach, the therapist stimulates the left side of
the patient’s body using a rough cloth, ice, or other material. The patient
is reminded to watch what the therapist is doing. Next, the patient stimulates
the affected side himself or herself while watching.
 In the transfer of training approach, the patient participates in tasks that
make it necessary to look toward the affected side, such as watching television.
For example, the television can be placed initially on the affected side.
A brightly colored tape track may be placed along the floor and the patient
may be instructed to walk or to guide the wheel chair along it.
RIGHT-LEFT DISCRIMINATION
A disorder in right left discrimination is the inability to identify the right
and left sides of one’s own body or that of the examiner. This includes inability
to execute movements in response to verbal commands that include the terms
“right” and “left”. Patients are often unable to imitate movements.
Clinically, the patient cannot tell the therapist which is the right arm and
which is the left. The right shoe cannot be discerned from the left shoe, and
the patient is unable to follow instructions using the concept of right left,
such as “turn right at the corner”. The patient cannot discriminate the right
from the left side of the therapist.
The lesion site is the parietal lobe of either hemisphere. A close relationship
between aphasia and deficits in right-left discrimination has been reported.
In non-aphasic patients, a relationship has been reported between general mental
impairment and right left discrimination.
 The patient is asked to point to body parts upon Command: Right ear,
left foot, right arm, and so forth. Six responses should be elicited on the
patient’s own body, on that of the therapist, and on a model or picture
of the human body. To rule out somatagnosia, the patient should be tested
first without the directional words.
Treatment
 In giving instructions to the patient, the words “right” and “left” should
be avoided. Instead, pointing or providing cues using distinguishing features
of the limb are more effective.
 Adapt the environment. The right side of all common objects such as shoes
and clothing should be marked with red tape or any other color may be used.
FINGER AGNOSIA
Finger agnosia can be defined as the inability to identify the fingers of one’s
own hands or of the hands of the examiner. This includes difficulty in naming
the finger upon command, identifying which finger was touched, and, by some
definitions, mimicking finger movements. This deficit usually occurs bilaterally
and is more common on the middle three fingers. Finger agnosia correlates
highly with poor dexterity in tasks that require movements of individual fingers
in relation to each other, such as buttoning, tying laces, and typing.
Finger agnosia may be the result of a lesion located in either parietal lobe,
in the region of the angular gyrus, or in the supramarginal gyrus. It is often
found in conjunction with an aphasic disorder, or with general mental impairment.
Bilateral finger agnosia with right-left discrimination, agraphia, and acalculia
is termed Gerstmann’s syndrome. A portion of sauguet’s test assessment is
recommended.
 The patient is asked to name the fingers touched by the therapist, with
the eyes open (five times) and if successful, with vision occluded (five
times).
 The patient is asked to point to the fingers named by the therapist on
the patient’s own hands (10 times), on the therapist’s hands (10 times),
and on a schematic model (10 times).
 The patient is asked to point to the equivalent finger on a life-sized picture
when each finger is touched by the therapist.
 The patient is asked to imitate finger movements for example, curl the
index finger, and touch the thumbs to the middle finger.
Treatment
 To apply sensory integrative principles, the patient’s discriminative tactile
systems are stimulated. A rough cloth can be used to rub the dorsal surface
of the affected arm, hand and fingers, and the ventral surface of the affected
fingers. Pressure can be applied to the ventral surface of the hand.
 To use the transfer of training approach, the patient is quizzed on finger
identification.
ANOSOGNOSIA
Anosognosia is a severe condition including denial, neglect, and lack of
awareness of the presence of severity of one’s paralysis. Presence of this disability
may compromize rehabilitation potential greatly, because it limits the patient’s
ability to recognize the need for, and thus to use, compensation techniques.
Typically, the patient maintains that there is nothing wrong and may disown
the paralyzed limbs and refuse to accept responsibility for them. The patient
may claim that the limb has a mind of its own or that it was left at home,
or in a cupboard. It has been observed that patients suffering from anosognosia
have a tendency to cover the paretic arm.
The lesion is usually located in the non-dominant parietal lobe, in the region
of the supramarginal gyrus.
 Anosognosia is assessed by talking to the patient. The patient is asked
what happened to his arm or leg, whether he is paralyzed, how the limb
feels, and why it cannot be moved.
 A patient with anosognosia may deny the paralysis, say that it is of no concern,
and fabricate reasons why a limb does not move the way it should be.
 It is extremely difficult to compensate for this condition. Safety is of paramount
importance in the treatment and discharge planning for patients suffering
from anosognosia, because they typically do not acknowledge that they
have a disability and will therefore, refuse to be careful.
SPATIAL RELATIONS DEFICITS

This group encompasses a constellation of deficits that have in common, a
difficulty in perceiving the relationship between objects in space or the
relationship between self and two or more objects. Research suggests that
the right parietal lobe has the primary role in space perception. Thus, a spatial
relations deficit most frequently occurs in patients with right-sided lesions
and resulting left hemiparesis.
 Spatial relations syndrome includes disorders of figure-ground discrimination,
form constancy, spatial relations, position in space, and topographical
disorientation. Additional visuospatial deficits, such as depth and distance
perception, will be discussed. Constructional apraxia and dressing apraxia
are sometimes viewed as spatial relations problems.
Figure-ground Discrimination
A disorder in visual figure-ground discrimination is the inability to visually
distinguish a figure from the background in which it is embedded. Functionally,
it interferes with the patient’s ability to locate important objects that are not
prominent in a visual array. The patient has difficulty ignoring irrelevant visual
stimuli and cannot select the appropriate cue to which to respond. This may
lead to distractibility, resulting in a shortened attention span, frustration, and
decreased independent and safe functioning.
Clinically, the patient cannot locate items in a pocket book or drawer, locate
buttons on a shirt, or distinguish the armhole from the remainder of a solid
colored shirt. The patient may not be able to tell when one step ends and
another begins on a flight of stairs, especially when walking down. The
predominant lesion is generally in the non-dominant parietal lobe but may
be located in any part of the brain.
Assessment
 Ayres Figure ground test: The subject must distinguish the three objects
in an embedded test picture, from a possible selection of six items. This
test was standardized on children but may be useful as a clinical tool in
identifying perceptual disorders in brain damaged adults. Normative data
have been generated for normal adult males.
 Functional tests: A white shirt can be placed on a white sheet, and the
patient is asked to point out the sleeve, buttons, and collar of a white
shirt, or to pick out a spoon from an unsorted array of eating utensils.
It is necessary to rule out poor eye sight, hemianopsia, visual agnosia,
and poor comprehension, to improve the validity of these assessment
techniques.
Treatment
 Compensation through cognitive awareness: The patient is taught to become
aware of the existence and nature of the deficit. The patient should be
cautioned to examine groups of objects slowly and systematically and should
be instructed to use other, intact senses when searching for items such
as clothing or utensils.
 Adaptation and simplification of the environment: Red tape may be placed
over the Velcro strap of the shoe or orthosis to aid the patient in locating
it. Few items should be placed in the patient’s drawers or nightstand, and
they should be replaced in the exact location each time. Brightly colored
tape can be used to mark the edges on stairs.
 With the functional approach, repeated practice is used in each specific
area of difficulty each practice session, incorporating verbal cues and touch
as adjuncts to vision.
 Using the transfer of training approach, the therapist should arrange for
practice in visually locating objects in a simple array, and progress to more
difficult ones.
Form Consistency
Impairment in form consistency is the inability to perceive or to attend to
subtle differences in form and shape. The patient is likely to confuse objects
of similar shape or not to recognize an object placed in an unusual position.
Clinically, the patient may confuse a pen with a toothbrush, a vase with a
water pitcher, a cane with a crutch, and so forth. The lesion site is the parieto-
temporo-occipital region of the non-dominant lobe.
Assessment
 A number of items similar in shape and different in size are gathered. The
patient is asked to identify them. One set of items might be a pencil, pen,
straw, toothbrush, watch, and the other might be a key, paper clip, coins,
and a ring. Each object is presented several times in different positions.
Visual object agnosia must be ruled out as a cause of poor performance
by first presenting objects separately and asking the patient to identify them
or to demonstrate how they are used.
Treatment
 With the transfer of training approach, the patient should practice describing,
identifying, and demonstrating the usage of similarly shaped and sized objects.
The patient should sort like objects and should be assisted to focus on
differentiating cues.
 To achieve cognitive awareness and compensate for the disability, the patient
must be made aware of the specific deficit. If the patient can read, frequently
used letters and words are taught to the patient and the patient is encouraged
to use vision, touch, and self-verbalization in combination when confused
about objects.
Spatial Relations Deficit

A spatial relations deficit, or spatial disorientation, is the inability to perceive
the relationship of one object in space to another object, or to oneself. This
may lead to, or compound, problems in constructional tasks and dressing.
Crossing the midline may be a problem for patients with spatial relations
deficits.
Clinically, the patient might find it difficult to place the cutlery, plate, and
spoon in the proper positions, when setting the table. The patient may be
unable to tell the time from a clock because of difficulty in perceiving the
relative positions of the hands. The patient may have difficulty learning to
position his or her arms, legs, and trunk in relation to the wheelchair to prepare
for transferring.
The lesion site is predominantly the non-dominant parietal lobe.
Assessment
 The therapist draws a picture of a clock and then asks the patient to fill
in the numbers and to draw in the hands to designate a particular time.
Patients with poor eye-hand coordination can be requested to place markers
in the appropriate positions instead of drawing numbers.
 Two or three objects are placed on a piece of paper in a particular pattern.
The patient is asked to duplicate the pattern.
 To improve the validity of these assessments, unilateral neglect and
hemianopsia should be ruled out as the causes of poor performance. If
these are present, position the stimulus array appropriately.
Treatment
 Using the transfer of training approach to improve the ability to orient
oneself to other objects, the patient can be given instructions on positioning
himself or herself in relation to the therapist or another object; for example,
“sit next to me”, “go behind the table”, “step over the line”. In addition,
the therapist can set up a maze of furniture. Having the patient copy block
or matchstick designs of increasing difficulty will increase awareness of
the relationship between one object and the next.
 With the sensorimotor approach, if the patient avoids crossing the midline,
activities that require crossing the midline, both motorically and visually,
can be incorporated into other therapeutic activities.
 One specific activity is to have the patient hold a stick in both hands.
The therapist guides it from the uninvolved side to the involved side. Later,
the patient can progress to manipulating the stick with only verbal or visual
cues, and finally to guiding it independently.
Position in Space
A deficit in the perception of position in space is the inability to perceive
and to interpret spatial concepts such as up, down, under, over, in, out, in
front of, and behind.
Clinically, if a patient is asked to raise the arm “above” the head during
a ROM assessment or is asked to place the feet “on” the footrests, the patient
may behave as if he or she does not know what to do.
The lesion is located in the non-dominant parietal lobe.
Assessment
 To assess function, two objects are used, such as shoe and a shoe box.
The patient is asked to place the shoe in different positions in relation to
the shoe box; for example, in the box, below the box, or next to the box.
 Alternatively, the patient is presented with two objects and asked to describe
their relationship. For example, a toothbrush can be placed in a cup, under
a cup, and so forth, and the patient is then asked to indicate the location
of the toothbrush.
 Another mode of assessment is to have the patient copy the therapist’s
manipulations with an identical set of objects. For example, the therapist
hands the patient a comb and a brush.
 The therapist then takes an identical set and places them in a particular
relationship to each other, such as the comb on top of the brush. The patient
is requested to arrange his or her comb and brush in the same way. Success
in this task may represent sufficient ability to use position in space functionally.
 Figure-ground difficulty, apraxia, in coordination, and lack of comprehension
should be ruled out when performing these assessments. Objects should
be positioned to avoid compounding of results with hemianopsia unilateral
spatial neglect.
Treatment
 To use the transfer of training approach, three or four identical objects
are placed in the same orientation. An additional object is placed in a different
orientation. The patient is asked to identify the odd one, and then to place
it in the same orientation as the other objects.
 The sensorimotor approach used for treatment of spatial relations is similar
to that used for treatment of disorders of position in space.
Topographic Disorientation
Topographic disorientation refers to difficulty in understanding and remembering
the relationship of one location to another. As a result, the patient is unable
to get from one place to another, with or without a map. This disorder is
frequently seen in conjunction with other difficulties in spatial relations.
Clinically, the patient cannot find the way from his or her room to the
physical therapy clinic, despite being shown repeatedly. The patient cannot
describe the spatial characteristics of familiar surroundings, such as the layout
of his or her bedroom at home.
The lesion site is the occipitoparietal lobe of the non-dominant hemisphere.
Assessment
 The patient is asked to describe or to draw a familiar route, such as the
society in which he or she lives, the layout of his or her house, or a major
nearby landmark. The impaired patient will be unable to succeed in this task.
Treatment
 Using the transfer of training approach, the patient practices going from
one place to another, following verbal instructions. Initially, simple routes
should be used, and then more complicated ones.
 Using the functional approach, important routes in the actual environment
or in the patient’s home are repeatedly practiced.
 Adapt the environment. Frequently travelled routes can be marked with
colored dots. The spaces between the dots are gradually increased and
eventually eliminated as improvement takes place.
 This is an example of taking a normally right-hemisphere task and converting
it in to a left-hemisphere task. In this instance, we take the spatial task
of remembering routes and substitute sequential landmarks to accomplish
the goal of getting from place to place.
 To reinforce cognitive awareness, the patient should be instructed not to
leave the clinic, room, or home unattended, because he or she may get
lost.
Depth and Distance Perception

The patient with deficits in these areas experiences inaccurate judgment of
direction, distance, and depth. Spatial disorientation may be a contributing
factor in faculty-distance perception.
Clinically, the patient may have difficulty navigating stairs, may miss the
chair when attempting to sit, or may continue pouring juice once a glass
is filled.
This may occur with a lesion in the right, non-dominant hemisphere,
particularly in the occipital lobe.
Assessment
 For a functional assessment of distance perception, the patient is asked
to take or to grasp an object that has been placed on a table. The object
may be held in front of the patient, in the air, and the patient is again
asked to grasp it. The impaired patient will overshoot or undershoot.
 To assess depth perception functionally, the patient can be asked to fill

a glass of water. A patient with depth perception deficit may continue pouring
once the glass is filled.
Treatment
 Help the patient become aware of the deficit (cognitive awareness).
 Stress the importance of walking carefully on uneven surfaces, particularly
the stairs.
 With the transfer-of-training approach, the patient is requested to place the
feet on designated spots during gait training. Also, blocks can be arranged
in piles 2 to 8 inches high. The patient is asked to touch the top of the
piles with the foot. This is done to re-establish a sense of depth and distance.
Vertical Disorientation
Vertical disorientation refers to a distorted perception of what is vertical.
Displacement of the vertical position can contribute to disturbance of motor
performance, both in posture and in gait. Early on, in recovery, most post-
CVA patients demonstrate some impairment in the sense of verticality. This
is not influenced by the presence or absence of homonymous hemianopsia.
Scores on one test for visual perception of the vertical position were found
to correlate with differences in walking ability.
An example of the way in which a person with distorted vertically views
the world and the way this may affect posture.
The lesion site is in the non-dominant parietal lobe.
Assessment
 The therapist holds a cane vertically and then turns it sideways to a horizontal
plane. The patient is handed the cane and asked to turn it back to the
original position. If the patient’s perception of the vertical position is distorted,
the cane will most likely be placed at an angle, representing the patient’s
conception of the world around him or herself.
Treatment
 The patient must be made aware of the disability. The patient should be
instructed to compensate by using touch for proper self-orientation, especially
when going through doorways, in elevators and on the stairs.
AGNOSIA
Agnosia is the inability to recognize familiar objects using one or more of
the sensory modalities, while often retaining the ability to recognize the same
object using other sensory modalities. All types of Agnosia represent impairment
in the transmission of the sensory signal, to the conceptual level.
Visual Object Agnosia

Visual object agnosia is the most common forms of agnosia. It is defined
as the inability to recognize familiar objects despite normal function of the
eyes and optic tracts. One remarkable aspect of this disorder is the readiness
with which the patient can identify an object once it is handled. Visual object
agnosia may occur with or without hemianopsia. The patient may not recognize
people, possessions, and common objects. Specific types of visual agnosia
are described below.
Simultagnosia, also known as Balint’s syndrome, is the inability to perceive
a visual stimulus as a whole. The patient perceives an entire array on a part
at a time. The lesion is in the dominant occipital lobe.
Prosopagnosia was traditionally considered to be the inability to recognize
faces as being familiar. This phenomenon is now thought to be related
to any visually ambiguous stimulus, the recognition of which depends on
evoking a memory context, such as different species of birds or different
makes of cars. Prosopagnosia is usually accompanied by visual field defects.
Bilaterally symmetric occipital lesions are thought to be responsible for this
deficit.
Color agnosia is the inability to recognize colors; it is not color blindness.
The patient is unable to name colors or to identify them on command, although
the ability to name objects is retained. Color agnosia is frequently associated
with facial or other visual object agnosias. It is usually the result of a dominant
hemisphere lesion. The simultaneous occurrence of left-sided hemianopsia,
alexia, and color agnosia is a classic occipital lobe syndrome.
The lesions associated with visual object agnosias are thought to occur
in the occipito-temporo-parietal association areas of either hemisphere; these
areas are responsible for the integration of visual stimuli with respect to memory.
The exact nature of the disability may be determined by the laterality of the
lesion. Color agnosia frequently accompanies diffuse dementia.
Assessment
 To asses this disorder, several common objects are placed in front of the
patient. The patient is asked to name the objects, to point to an object
named by the therapist, or to demonstrate its usage. It is important to rule
out aphasia and apraxia.
Treatment
 Using the transfer of training approach, drills can be used to practice
discrimination between faces that are important to the patient, in discrimination
between colors and common objects.
 The therapist should assist the patient in picking out salient visual cues
for relating names to faces.
 With compensation techniques, the patient is instructed to use intact sensory
modalities such as touch or audition to distinguish people and objects.
Auditory Agnosia
Auditory agnosia refers to the inability to recognize non-speech sounds or
to discriminate between them. This rarely occurs in the absence of other
communication disorders.
The patient with auditory agnosia cannot tell, for example, the difference
between the ring of a doorbell and that of a telephone, or between a dog
barking and thunder.
The lesion is located in the dominant temporal lobe.
Assessment
 Assessment is usually carried out by a speech therapist.
 The patient is asked to close the eyes and to identify the source of various
sounds. The therapist rings a bell, honks a horn, rings a telephone, and
so forth, and asks the patient to identify the sound (verbally or by pointing
to a picture).
Treatment
 Treatment generally consists of drilling the patient on sounds, but this has
not been found to be particularly effective.
Tactile Agnosia or Astereognosis

Tactile agnosia, or astereognosis, is the inability to recognize forms by handling
them, although tactile, proprioceptive, and thermal sensations may be intact.
This condition commonly causes difficulties in ADLs, in as much as many

self-care activities that are normally done in the absence of constant visual
monitoring require the manipulation of objects. If tactile agnosia is present
in combination with unilateral neglect or sensory loss, performance in ADLs
may be severely hampered.
If a patient is handed an object (key, comb, safety pin) with vision occluded,
the patient will fail to recognize it.
The lesion is in the parieto-temporo-occipital lobe (posterior association
areas) of either hemisphere.
Assessment
 The patient is asked to identify objects placed in the hand by examining
them manually without visual cues.
Treatment
 With the transfer of training approach, the patient practices feeling various
common objects, shapes, and textures with vision occluded. The patient
is instructed to immediately look at the object for visual feedback and
note special characteristics of the object.
 To achieve cognitive awareness, the patient is made aware of the deficit
and is instructed in visual compensation.
Olfactory Agnosia
It is the inability to recognize familiar smells.
The smell of gas, of smoke and of burnt food is ignored and this has
implications for safety.
APRAXIA
Apraxia is a disorder of voluntary learned movement. It is characterized by
an inability to perform purposeful movements, which cannot be accounted
for by inadequate strength, loss of coordination, impaired sensation, attention
difficulties, abnormal tone, movement disorders, intellectual deterioration, poor
comprehension, or uncooperativeness. The patient is unable to accomplish the
task even though the instructions are understood. Many patients with apraxia
also present with aphasia, and the two disorders are sometimes difficult to
distinguish.
Ideomotor and ideational apraxias are generally thought to be the result

of dominant hemispheres lesions and may be particularly difficult to assess
in the patient with aphasia. Although aphasia and apraxia often occur together,
there is not a strong correlation between the severity of the aphasia and the
severity of the apraxia. Apraxia is a disorder of skilled movement and not
a language disorder. Dressing apraxia and constructional apraxia occur with
lesions in either hemisphere.
Ideomotor Apraxia
Ideomotor apraxia refers to a breakdown between concept and performance.
There is a disconnection between the idea of a movement and its motor execution.
It appears that information cannot be transferred from the areas of the brain
that conceptualize to the centers for motor execution. Thus, the patient with
ideomotor apraxia is able to carry out habitual tasks automatically and describe
how they are done but is unable to perform a task upon command and is
unable to imitate gestures. Patients with this form of apraxia often perseverate,
that is, they repeat an activity or a segment of a task over and over, even
if it is no longer necessary or appropriate. This makes it difficult for them
to finish one task and then to go on to the next. Patients with ideomotor
apraxia appear most handicapped when requested to perform tasks that require
use of many implements and that have many steps. This form of apraxia can
be demonstrated separately in the facial areas, upper extremity, lower extremity,
and for total body movements. Patients with apraxia are often observed to
be clumsy in their actual handling of objects. Impairment is often suspected
when observing the patient in ADLs or during a routine motor assessment.
 Several examples of ideomotor apraxia follow: the patient is unable to “blow”
on command. However, if presented with a bubble wand, the patient will
spontaneously blow bubbles.
 The patient may fail to walk if requested to in the traditional manner. However,
if a cup of coffee is placed on a table at the other end of the room and
the patient is told, “Please have some coffee”, the patient is likely to transverse
the room to get it.
 A male patient is asked to comb his hair. He may be able to identify the
comb and even tell you what it is used for; however, he will not actually
use the comb appropriately when it is handled to him. Despite this observation
in the clinic, his wife reports that he combs his hair spontaneously, every
morning.
 A female patient is asked to squeeze a dynamometer. She appears not to
know what to do with it, although her comprehension is adequate, the task
has just been demonstrated, and it is clear that she has adequate strength.
The lesion is generally found in the dominant supramarginal gyrus.
Assessment
 The Goodglass and Kaplan test for apraxia is comprised of universally
known movements, such as blowing, brushing teeth, hammering, shaving,
and so forth. It is based on what the authors consider a hierarchy of difficulty
for patients with apraxia. First the patient is told, “Show me how you would
bang a nail with a hammer.” If the patient fails to do this or uses his
or her fist as if it were a hammer, the patient is asked, “Pretend to hold
the hammer”. If the patient fails following this instruction, the therapist
demonstrates the act and asks the patient to imitate it. The patient with
apraxia typically will not improve after demonstration but will improve
with use of the actual implements. Ability to correct oneself on following
verbal suggestions is considered to counter indicative of apraxia.
 The therapist sits opposite the patient. The patient is asked to imitate different
postures or limb movements. The patient with apraxia is unable to imitate
postures.
Treatment
 Anderson and Choy suggest the modification of instructional sets as follows:
Speak slowly and use the shortest possible sentences. One command should
be given at a time, and the second command should not be given until
the first task is completed. When teaching a new task, physically guiding
the patient through the task is necessary. It should be completed in precisely
the same manner each time. When all the individual units are mastered,
an attempt to combine them should be made.
 A great deal of repetition may be necessary.
 Family members must be advised to use the exact approach found to be
successful in the clinic.
 Performing activities in as normal an environment as possible is also helpful.
 Using the sensorimotor approach, multiple sensory inputs are used on the
affected body parts in order to enhance the production of appropriate motor
responses.
Ideational Apraxia
Ideational apraxia is a failure in the conceptualization of the task. It is an
inability to perform a purposeful motor act, either automatically or on command,
because the patient no longer understands the overall concept of the act, cannot
retain the idea of the task, and cannot formulate the motor patterns required.
Often the patient can perform isolated components of a task but cannot combine
them into a complete act. Furthermore, the patient cannot verbally describe
the process of performing an activity, describe the function of objects, or
use them appropriately.
 Sharpless claims that ideational apraxia is unusual complication of stroke
and is often present concomitantly with agnosias.
Ideational apraxia is typified by the following behavior: When presented
in the clinic with a toothbrush and toothpaste and told to brush the teeth,
the patient may put the tube of toothpaste in the mouth, or try to put toothpaste
on the toothbrush without removing the cap. Furthermore, the patient may
be unable to describe verbally how tooth brushing is done. Similar phenomenon
may be evident in all aspects of ADL and so may limit the safety and potential
independence of patient. It has been shown that patients with ideational apraxia
test poorly in the clinical situation and appear more able to perform ADLs
at the appropriate time and in a familiar setting.
The lesion causing ideational apraxia is thought to be in the dominant
parietal lobe. This deficit also may be seen in conjunction with diffuse brain
damage such as cerebral arteriosclerosis.
Assessment
 The tests for ideational apraxia are essentially the same as those for ideomotor
apraxia. The major difference to be expected in response is that the patient
with ideomotor act spontaneously and automatically at the appropriate time,
but the patient with ideational apraxia is unable to do so.
Treatment
 The treatment techniques used are the same as those for ideomotor apraxia.
Constructional Apraxia
 Constructional apraxia is characterized by faulty spatial analysis and
conceptualization of the task. Normal constructional skills encompass the
capacity to understand the relationship of parts to a whole. This ability
is critical in activities such as drawing, dressing, building from a model,
copying block design and the like. Performance of these complex tasks
requires a combination of visual perception, motor planning, and motor
performance.
 Thus, constructional apraxia is most evident in the inability to produce

two-or three-dimensional forms by drawing, constructing, or arranging blocks
or objects spontaneously or upon command. It hampers the patient’s ability
to manipulate the environment effectively because of an inability to construct
things from components parts. Although able to understand and to identify
the individual components, the patient cannot place them in to a correct,
meaningful relationship.
 This deficit is found in patients with lesions to either hemisphere, but upon
testing, there is a difference in the quality of their responses. Patients with
right-sided lesions appear to be more severely affected that those with left
brain involvement. They clearly lack the visuospatial ability to succeed
in a task. Additionally, they lack perspective, are unable to place a figure
in the appropriate position in space, and seem unable to analyze parts in
relationship to each other.
 Patients with left-hemisphere damage seem to lack the analytic or planning
ability necessary to initiate and perform movements in sequence to complete
a constructional task. In a study by Mcfie and Zangwill, the left-lesioned
group (in contrast to the right-lesioned group) rarely presented with unilateral
neglect or topographic disorientation but often demonstrated impairment
in constructional tasks in conjunction with general intellectual impairment.
 The presence of constructional apraxia is thought to be related to body
scheme disorders, and often results in difficulty in dressing and diminished
performance in other ADL skills.
 Constructional apraxia is demonstrated, for example, by a patient who
understands all about sandwiches and what they are for but is unable to
assemble one, even with all ingredients laid out in front of them.
Lesions are located in the posterior parietal lobe of either hemisphere.
Constructional apraxia is more common and more severe in patients with right-
hemisphere lesions. Right-sided lesions that results in constructional apraxia
tend to be less diffuse than left-sided lesions.
Assessment
 The patient is asked to copy a drawing of a house, a flower, or a clock
face.
 The patient is requested to copy geometric designs (e.g., circle, square,
or t-shape).
 The patient is instructed to copy block bridges, matchstick designs, or
pegboard configurations. Initially, only three pieces are used in a jigsaw
and a progression is made to use more.
 Visuoconstructive difficulties found with right and left-sided lesions

demonstrate qualitative differences, as described above. In response to the
assessment materials, patients with right-sided damage tend to draw on
the diagonal and neglect the left side of the page. They draw pieces of
the picture without any coherent relationship to each other. Thus, their
drawings tend to be complex, yet unrecognizable. They have immense
difficulty with copying or constructing anything in three dimensions, are
not helped by the presence of a model or by landmarks in a picture, and
do not generally improve with practice.
 In contrast, the drawings of patients with left-hemisphere damage are usually
more recognizable. They are characterized by great simplicity. Patients with
left-sided lesions draw slowly and hesitatingly, are often unable to draw
angles, and have general difficulty in execution. In contrast to that of right-
hemisphere stroke victims, their performance often improves with the aid
of a model, the use of landmarks in drawings, and with repeated trials.
Short-term visual memory impairment is thought to be associated with
constructional apraxia in patients with right-sided lesions.
 Verbal and comprehension difficulties, poor manual dexterity, and the presence
of homonymous hemianopsia must be ruled out during assessment for this
disorder.
Treatment
 With the transfer of training approach, the patient is asked to practice copying
geometric designs, both by drawing and by building. Initially, simple patterns
are used, progressing to the more complex. Patients with left-hemisphere
lesions may benefit from the use of landmarks, and then their gradual
withdrawal as skill improves.
Dressing Apraxia
Dressing apraxia is inability to dress oneself properly owing to a disorder
in body skin or spatial relations rather than difficulty in motor function.
For example, patients put on clothes upside down inside out, etc.
The lesion site is non-dominant occipital or parietal lobe.
Assessment
 An assessment technique includes clinical observation; constructional apraxia
and dressing apraxia has a high degree of correlation.
Treatment
 To develop a sequence and pattern for dressing which patient practices
daily. A key to successful performance is proper positioning of garments,
color codes for right and left, start buttoning from bottom and to color
code inside and outside of garments.
COGNITIVE DYSFUNCTION
Cognition
It is an ability of the brain to process, store, retrieve and manipulate information.
Attention, orientation, memories are the basic process upon which are built
the higher cognitive functions. Higher cognitive functions include:
 Fund of knowledge
 Ability to manipulate old knowledge (e.g. calculation)
 Problem-solving
 Social awareness
 Abstract-thinking.
Attention
It is an ability to focus on specific stimulus without being distracted.
Evaluation: Digit repetition, random letter test, etc.
Orientation
Orientation to time, place and person is evaluated.
Memory
The ability to process, store and retrieve information depends on intact memory
system. Weschler memory scale is commonly used by neuropsychologist. We,
as therapists, need to evaluate the status of immediate memory, STM and
LTM to plan any relearning program for the patients. Memory dysfunctions
are commonly seen after frontal lobe lesions.
Assessment
 Immediate memory: Digit repetition
 Ask the patient to remember four words (e.g. brown, honesty, tulip, eye)
and then test this immediate recurs after 5 minutes, 10 minutes and 30
minutes. This examines verbal memory.
Visual Memory
It is assessed by pointing to four objects in the room and having the patient
recall them immediately, after 5 minutes and at the end of the session.
Problem-solving
It requires both an intact fund of knowledge and the ability to manipulate
and apply this information to new or unfamiliar situations. A deficit in problem
solving will affect all phases of the patient’s daily life.
Functional Problems
 Unable to figure out which bus to take
 How to plan a meal
 Experiences difficulty in social situations.
Assessment
 Proverb interpretation, e.g. Rome was not built in a day
 Social awareness
 Mathematical problems
 Conceptual series completion
 Verbal similarities.
Emotional Dysfunction
 Depression denial, anxiety and fear may occur as a result of the CVA
 Lesions of left or right hemisphere may produce differences in effective
behavior
 Lesions to right are thought to ‘release’ talking whilst lesions to left are
thought to reduce talking (Kolb and Whisaw, 1980)
 Always differentiate between depressive catastrophic reaction occurring with
left hemisphere lesion versus indifference reaction with right hemisphere
lesion.
Clinical Co-relation
 Attention seeking and dependent on external support
 Try to isolate themselves
 Afraid of physical exertion
 Irritable
 Easily distractable.
STRATEGIES TO IMPROVE COMMUNICATION

IN A PATIENT HAVING SPEECH DISORDER
 Cut down on outside distractions
 Speak slowly and look at the person you are talking to
 Use simple and concrete language
 Do not change topics quickly
 Use short and clear sentences
 Try to convey only one idea at a time
 Pause between phrases
 Use less ambiguous phrases
 Do not shout. (If you suspect hearing loss, arrange for a hearing test)
 Check whether the patient understands you
 Check whether you understand the patient
 Encourage the patient
 Do not pretend that you understand
 Do not expect too much of yourself. The important thing is to keep trying.
So that the patient does not experience social isolation and lack of human
contact.
THERAPEUTIC GUIDING TECHNIQUES

In the cases of brain damage in children and adults, guiding the patient’s
hands and body during performance of actual tasks and learning of the movement
have proved amazingly successful by this unique technique, perceived and
developed by a Swiss neuropsychologist Dr Félicie Affolter over many years.
This technique has proved appropriate at any stage of treatment. The technique
enables the patient to improve both his physical and cognitive abilities (Affolter
1981 and 1991). To facilitate the learning process the task must be goal, oriented
and clearly identified by the patient. The most elementary motor processes can
be influenced by specific cognitive states such as expectations, goal and knowledge
of the result. Goal-oriented tasks help to inhibit spasticity and task must be
selected in real life situation and involve problem-solving activities. The activity
should be planned at the patient’s level of performance, this is judged by observing
the patient’s performance. The patient’s attention span and understanding of
the activity are prerequisite for effective learning. Considering the complex
processes involved in learning, therapies based on reflex responses do not help
the patient to relearn to function adequately and independently. In the normal
development of an infant, various reflexes become modified and are organized
into goal-directed activities (Piaget 1969).
Criteria for Optimal Learning

 Interaction with the environment through tactile kinesthetic channel
 To work with tacto-kinesthetic inputs in real life situation
 Successful performance of the problem-solving tasks
 Repetition with variation
 Meaningful goal-oriented activities.
In the treatment of cognitive and perceptual deficits, apraxias and agnosias,
the treatment aims at the root of the problem to achieve maximum lasting
recovery.
The patient who is unable to learn through his environment because he
cannot feel or move normally, the therapist aims to achieve the necessary
interaction by guiding the patient’s hands and body to ensure the maximum
tactokinesthetic input in inhibited postural patterns.
Considerations for guiding technique:
 Position of the patient and the therapist
 Stability
 Quiet environment
 Activities are guided in non-verbal realm or in a soothing voice. Avoid
loud strong commands that distract the patient
 Alternating activities with both hands
Guiding is not only invaluable as treatment intervention but provides important
information for the continuous assessment of patient’s level of performance
at his optimal level.
 The patient is quiet
 His eyes are directed towards the task
 His muscles relax and unwanted motor activity is reduced to minimum
 Spasticity reduces and if hypotonus present alert tension is felt
 The therapist may feel forward movement in appropriate direction and active
participation or notice a slight movement of his head towards the object
require for the next step in the task. Close observations during the activity
will reveal improvement or the difficulties encountered by the patient.
 The ability to feel through an intermediary tool or an object and its use
permits skillful activities like surgery, painting, etc.
The concept of therapeutic guiding makes a big difference to the patient
during his full course of rehabilitation. These techniques enable him to achieve
more positive outcome and better adjustment in the society. There should be
no limits placed on what the patient can achieve.
C H A P T E R
16
Complications and their
Management
Hemiplegia is a condition which is manifested due to variety of causes which

are enumerated before. After the onset of these symptoms, complications may
occur which are as follows. The management of the complication becomes
a daunting task because of the fact that the one half of the body is paretic
and the patients usually are apprehensive about their recovery.
SHOULDER PAIN
The painful shoulder is one of the most distressing of the problems faced
by the hemiplegic patient. The pain has been described as affecting 70% of
hemiplegic patient. (Caldwell et al, 1969).
To carry out the treatment successfully, it is important to review “the three
areas” in the shoulder joint complex which is inherently a very mobile joint
and the stability is partly compensated by the surrounding musculature (Zinn
1973).
 The mobility of scapula on thorax
 The normal scapula-humeral rhythm and the factors influencing the shoulder
joint mobility and stability
 Muscular attachments—the various muscles acting in harmony as the
stabilizers and prime movers. These muscles have their attachments to cervical,
thoracic and lumbar spine and the rib cage. The upper extremity can function
effectively only on a stable trunk. The abdominals stabilize the trunk on
thorax, and during the movement of the arm, there is a constant subtle
activity in the trunk flexors and extensors. The shoulder problems are divided
in to 3 main groups:
1. The subluxated shoulder
Complications and their Management 355
2. The painful shoulder

3. The shoulder hand syndrome.
Associated shoulder pain is the most common of the complications post
hemiplegia. The causes are: The decreased tone around the hemiplegic shoulder.
The shoulder joint has only muscular attachment with the scapula. The stability
of the shoulder is compromised for the mobility. Usual subluxation is inferior
subluxation. The other cause is malhandling of the patient in the initial stage.
Turning on the hemiplegic side with the shoulder trapped in the internal rotation
under the body can cause severe shoulder pain. When the patient is assisted
for sitting up in the bed or during turning, if the affected upper limb is pulled
abruptly, it can harm the shoulder. The loosely hanging hemiplegic upper limb
during sitting and standing will have effect of gravity and, in turn can damage
the shoulder due to lack of tone in
muscles around shoulder and scapula.
The best approach to this problem
is the prevention. Education regarding
the handling of the patient to the nursing
staff and the relatives of the patient can
prevent the problems to a great extent.
If the problem has already occurred, then
early electrical stimulation to the
shoulder and scapular muscles with the
shoulder subluxation strap will ease out FIGURE 16.1: TNS for reflex sympathetic
the problem. The pain can be taken care dystrophy (RSD) left upper limb, left
of by the transcutaneous nerve hemiplegia
stimulation (TNS) (Figure 16.1) and
interferential therapy (IFT). If not treated
early, it can cause traction on the brachial plexus and can result into shoulder
hand syndrome and sudek’s osteodystrophy. Early weight-bearing with proper
handling of the part and joint approximation will improve the tone around the
shoulder joint and will stabilize the shoulder. Ice application is a vital therapy
for pain relief. Quick ice will facilitate the muscles.
THE SUBLUXATED SHOULDER

The subluxated shoulder occurs in early stages of stroke when:
 The stabilizing biomechanical factors are disturbed; the position of scapula
on thorax is in relation to the glenohumeral joint
 Loss of head, neck and truncal activity.
Inferior subluxation is a very common feature, subluxation itself is not

painful, but it may progress to a painful shoulder. Maintenance of scapula
rotation on thorax and full pain free mobility of the glenohumeral joint will
avoid the pain in the joint.
Treatment Aim is Threefold

 Proper positioning and handling techniques in bed and in sitting position
 Passively orient the position of scapula in relation to glenohumeral joint
 Restore normal locking mechanism and stimulate muscle activity in hypotonic
trapezius, deltoid, supraspinatous, sternomastoid and truncal muscles.
Slings
Do not place the subluxated arm in sling for the immobilized arm interferes
with the body image; reinforces flexor tone impairing postural support and
impending gait pattern (Voss 69). Neurologist Oliver Sacs (1995) mentions
after undergoing surgery for his right shoulder, “I am adapting, learning all
the while with my toes to learn a new balance pattern’.
Causative Factors
As described above, improper handling of the shoulder girdle in the acute
stage of stroke is the main cause of pain when the arm is elevated without
proper protraction of scapula and external rotation of the humerus, this results
in delayed rotation of the scapula and the greater tuberosity of the internally
rotated arm impinges on the acromian causing pain and joint limitation beyond
90°–100°. Improper positioning in bed when the patient directly lies on his
shoulder joint or is pulled from the shoulder during transfers are also common
factors. If the causative factors are not eliminated, constant trauma increases
pain beyond patient’s tolerance.
Treatment
The therapeutic approach is to gently mobilize the scapula and glenohumeral
joint (Maitland techniques), gentle mobilization of adverse neuromuscular tension
(Butler techniques). As the pain reduces, gently perform passive movements
in small ranges, mobilize the shoulder through the pelvis girdle rotations to
normal side in supine-lying. If the sensations are intact, warm sponges, TENS
and ultrasound can be used, taping and ice help in reducing pain considerably.
Approach is to work on head-neck orientation, encourage truncal activity, gentle
mobilization of the scapula to achieve normal scapulo-humeral rhythm by

inhibiting spasticity and facilitate muscle activity.
Pulleys
It has been assumed that pulleys and shoulder wheel aid to maintain and
increase joint mobility, but on the contrary, the patient traumatizes his own
shoulder in attempt to force the internally rotated and inactive arm in to elevation
and abduction without adequate scapular rotation. (Najenson et al, 1971), (Devise,
86). There are three disadvantages of pulleys and shoulders wheel.
 Loss of scapular stabilization
 Loss of external rotation
 Compensatory extension and lateral rotation of the spine decreasing
glenohumeral mobility.
SHOULDER HAND SYNDROME

(REFLEX SYMPATHETIC DYSTROPHY)
 Occurs most commonly in first 3 months, about 12.5% of hemiplegic patients
are affected (Davies), swollen hand is associated with pain in the shoulder,
its dull aching pain, causative factors are the imbalance of muscle tone
and loss of selective muscle activity constantly places the wrist in flexion
and ulnar deviation. The swelling on the dorsum of the hand is caused
by the obstruction of venous drainage. The inflamed hand is swollen with
skin discoloration, a marked hard, tender ganglion-like prominence appears
in the center of the dorsum of the wrist. There is marked tenderness of
wrist and fingers with limitation of joint ranges, the MP and IP joints are
in extended position with loss of index finger-thumb space. There is associated
loss of supination and shoulder girdle mobility. This can also lead to carpal
tunnel syndrome in few cases.
 Over stretching of tight painful flexors tendons while-weight-bearing exercises
or forceful passive movements of the wrist and fingers predisposes the
hand in inflammatory reaction of shoulder hand syndrome.
 Treatment approach is to prevent all the causative factors, should the
patient complain of pain or discomfort, the therapist should immediately
change his treatment techniques.
 Main aim is to reduce edema, pain and joint stiffness. Rest the wrist in
neutral cock-up splint. Position the forearm well in chair and elevate the
arm about heart position in bed. The arm should never be left to hang
down. The therapy session should be totally pain-free. Icing and compressive
crepe bandage aid in reducing swelling.
 Contraindications
Therapists dread soft tissue contractures and tend to be too vigorous while
treating swollen hand, this feature inflames the joints. The rule here is
too little rather than too much (Davies, 1977). Self-ranging flexion, elevation
and abduction exercises are contraindicated.
 Conclusion
Importance of understanding the exact nature of shoulder problem, early
detection, careful supervision of handling and treatment, techniques,
systematic evaluation and with symptom specific treatment this painful
complication can be avoided. In spite of prophylactic measures should this
problem arise, they can be overcome if detected early, and never ever working
in to pain for mobilization or weight-bearing. The treatment strategies are
based on interrelationship between orthopedic and neurological factors. Once
the pain is under control, there is good steady progress and the patient
is motivated partner.
FRACTURES
Hemiplegic patients can fall due to lack of balance and can fracture their
limbs. If the bone is broken on the hemiplegic side, then the immobilization
can deprive the patient of the physiotherapy and the recovery is delayed. It
can cause additional stiffness, and pain can increase spasticity and thus, further
complicating the matter. If the fracture is on the uninvolved side, it may render
the normal side useless of any functional activity and dependence of the patient
increases. With lower limb fractures, it may take around 4 to 6 months for
the patient to get back to normal functional activities. Commonest sites of
fractures are: neck humerus, radial head, Colles’, intertrochanteric and neck
femur.
Patient and careful approach of the physiotherapist will improve the condition.
For the prevention, the patient should be not left alone, while he does not
get enough balance to handle himself.
THALAMIC PAIN SYNDROME

This condition is of severe burning pain which the patient is unable to bear
due to thalamic lesions. There are severe unpleasant sensations on one half
of the body. This condition is unfortunate and difficult to handle. Apart from
the drugs, TNS and IFT, desensitization and application of pressure over body
parts can be used effectively. Weight-bearing on the affected site can ease
out the symptoms. A very patient approach on the part of the physiotherapist
with enough care is required for effectiveness.
OUTBURST OF LAUGHING AND CRYING

As such, the thalamic pain syndrome and the outbursts of laughing and crying
are both thalamic lesion problems. In certain thalamic lesions, the patient cannot
have control on the emotions. The emotional discharges are uncontrolled and
hence, the patient becomes emotionally viable even with a slight stimulus
or many a time, with no stimulus at all. This condition is very disturbing
for the patient and is embarrassing too. The people around might feel that
the patient has lost the mental balance but it is not the case. The patient’s
intelligence has no effect due to this problem. Autosuggestions and understanding
can control these symptoms at a long run. The patient needs to count, the
number of times a day, this outburst occurs and cautiously try to minimize
the outbursts. Meditation and chanting of mantras will help to cope up with
the situation.
TIGHTNESS-CONTRACTURES-DEFORMITY
Moderate-to-severe spasticity on the affected site coupled with the lack of
proper stretching exercises right from the acute stage may produce tightness
of the muscles in which the resting length of the muscle is decreased. If
a faulty exercise like resisted exercises of the spastic muscles is done without
complete stretching of the muscles, the tightness of the muscles will increase
fast. The tight muscles will have a newer length and hence, the length tension
relationship of the muscular action on the joint is altered and the efficiency
of the muscular contraction is further lessened. This is a vicious cycle. The
tight muscles can be relaxed and newer better length is achieved by adequate
stretching of those muscles. These exercises are continued for maintenance
of normal length of the tissues. Splints help to keep the part in a position
where tightness can be prevented.
If muscular tightness is not tackled with, it may permanently have decreased
length which does not increase even with passive stretching. This is known
as contracture. There is no therapy for contracture and hence, they should
be prevented at all cost. If the contractures have already occurred, surgical
intervention of muscle tissue lengthening can be done but, with little effect
due to the spasticity. Night splints can be used for maintenance of the muscular
and soft tissue length. If contractures are neglected, the other structures like
the ligaments, joint capsule, cartilage of the joint, will lose their physiology
and the deformities of the joints and the entire affected limb will set in.
This is not uncommon in rural India, where physiotherapy services are
unavailable. Deformities alter the normalcy of the body parts totally and
the patient’s chances to recover as before diminish. Counseling, training
to adjust to newer body challenges will help to cope up with this difficult
situation to some extent.
The treatments includes ice application for pain relief and decrease
in spasticity pre and post physiotherapy sessions, splintage for positioning
of the body parts in a stretched condition, stretching exercises to maintain
muscle length, passive exercises to maintain and increase range of motion
of joints and surrounding structures and active motor control activities
to prevent spastic muscles to over contract. All the spasticity relieving
methods should be incorporated, as early as possible, to prevent this
dangerous complication, which impairs the patient’s normal recovery
phase.
PUSHER’S SYNDROME
Pusher’s syndrome is a very severe condition which is characterized by the
fact that the patient will take the weight on the hemiplegic side by ‘push’
from the sound side. The push from the sound side is so strong that the
patient totally leans on the hemiplegic side and falls over in sitting position.
Even in lying, the patient pushes on to the bed with the sound side and hence,
the midline orientation which is of paramount importance, is lost. As the therapy
becomes difficult right from the initial stages, the prognosis is poor. The patient
takes a long time to register the normal postural reflex mechanism, which
is a base for all the motor activity. As in lying and sitting, when the patient
is brought to standing, the push from the sound side will not allow the patient
to stand erect without support. Many a times, the push is so strong that even
with support, it is difficult for the therapist to make the patient do any activities
in sitting or standing position.
Treatment for the pusher’s syndrome is extremely difficult for the reasons
discussed above. Moreover, the patient usually exhibits other perceptual problems
which complicate the matter further. The line of treatment would be to make
the patient be in midline in all the activities and postures right from the initial
stages. Strategies which incorporate manual shifting of the weight on to the
sound side and dynamic trunk control with the vestibular ball are employed.
Visual feedback for the midline orientation with strong verbal commands is
often necessary.
Associated Problems
Associated conditions like the speech involvement make it difficult for the
patient to communicate effectively and hence, the frustration which may generate
from it may cause increased spasticity in affected limbs, depression and hence,
delayed recovery.
 Prolonged bedrest in severe cases of disability causes pressure sores. If
they are not treated timely, they may lead to infection and septicemia and
may even lead to death. Pressure sores or the bed sores can be prevented
by skin breathing, i.e. turning the patient frequently, once in 45 minutes
to 1 hour. This will ease out the pressure on the dependent site and skin
circulation will improve. Devices such as air bed, water bed, and ripple
bed can minimize the chances of pressure sores but, nevertheless, turning
the patient frequently and keeping good hygiene of the part has no alternative.
Other complications of prolonged lying are pneumonitis and deep venous
thrombosis. The pneumonitis can be prevented by early chest and pulmonary
physiotherapy in form of deep breathing, coughing and huffing, segmental
breathing exercises, incentive spirometry and percussions and vibrations.
After the complication has already occurred, postural drainage along with
suction and above mentioned physiotherapy will dilute the secretions and
help in clearing the lungs of the secretions.
Deep venous thrombosis or the DVT can be prevented by regular rhythmic
contractions of the muscles of the lower limbs, especially calf muscles.
It will maintain the venous return and will not allow the blood to become
stagnant. On an hourly basis, passive physiotherapy of the lower limbs
can be given in all patients to minimize the risk. The ripple stocking will
prevent this complication. Post DVT, a very careful approach is employed
and the experienced physiotherapist will do movements so as not to create
further complication.
 Complications of the general systems are dealt with by the experts of that
system effectively. Timely referral will take care of the same.
C H A P T E R
17
Adjunct Therapies
BIOFEEDBACK
Electromyographic biofeedback (EMG-BFB) may be used to improve motor
functions in patients with hemiplegia. This technique allows patients to alter
motor unit activity based upon audio and visual feedback information. Thus,
firing frequency can be decreased in spastic muscles, or increased, along with
recruitment of additional motor units, in weak, hypoactive muscles. Patients
in the chronic stage or patients in late recovery for whom spontaneous recovery
is more or less complete have consistently demonstrated positive results that
may be attributed to biofeedback therapy. Benefits include improvements in
ROM, motor control, function, and relaxation. Most studies indicate that its
greatest effectiveness is achieved when it is used as an adjunct to regular
therapy in a combined approach. Following an initial training period, EMG-
BFG can also be self-administered, allowing patients to practice on their own.
Successful biofeedback applications in the trunk and lower extremity have
focused on improving posture and balanced control of ankle and knee muscles.
Programs typically begin training in the more dependent postures (e.g. sitting)
and gradually progress to more upright postures. Dynamic control using feedback
during gait has also been utilized. Electromyography or electrogoniometric
information can improve control of the limb and eliminate problematic gait
deviations such as genu recurvatum or limited dorsiflexion in swing. Limb
load devices that give feedback about the amount of loading or weight-bearing
on the hemiplegic limb have also been effective in improving gait. Patients
receiving this training demonstrate more normal weight-bearing and stance
times on their affected limb and increased swing times on their unaffected
limb. Upper extremities applications in stroke rehabilitation have largely focused
on relaxing the spasticity of muscles such as pectoralis major, biceps, or wrist
Adjunct Therapies 363
and finger flexors. Significant improvements in initiating voluntary finger

extension have also been reported following upper extremity biofeedback
training.
ELECTRICAL STIMULATION
Neuromuscular electrical stimulation (NMES) may be used with patients
recovering from stroke to facilitate voluntary motor control, to temporarily
reduce spasticity, and/or to substitute for an orthosis. Neuromuscular electrical
stimulation has been shown to increase the ability of muscle to exert force,
by preferentially activating the fast-contracting motor units. Effective treatment
results in stroke rehabilitation have been reported using NMES to improve
dorsiflexor function, wrist extension function, and spasticity reduction associated
with antagonist muscle activation. The term functional electrical stimulation
(FES) refers to the regular use of ES in functional tasks. Functional electrical
stimulation to the posterior deltoid and supraspinatus muscle has been used
in patients with stroke to re-establish glenohumeral alignment and reduce
subluxation. It has also been used to assist dorsiflexor function in place of
an AFO or as an adjunct. Patterned FES, in which a multichannel program
was developed from individual profiles of EMG and anthropometric
measurements yielded significant improvement in active ROM of paralyzed
limbs. Since this group of patients had limbs that have been paralyzed for
more than six months, the results suggest a significant CNS learning effect
from FES.
Electrical stimulation has a very
distinct role in the field of
physiotherapy. Its importance has
been stated in many research works
and it enjoys a respectable position
in our field. Its effect on maintenance
of the physiology of tissues after a
lower motor neuron lesion is very FIGURE 17.1: Electrical stimulation to
knee extensors, right hemiplegia
well accepted. Its effect in gaining
the near normal tetanic contractions using the faradic type of current is well-
known (Figure 17.1). TNS or the transcutaneous electrical nerve stimulator
is highly effective in relieving the pain in any part of the body. It also can
activate the sensory system of the body and help in restoring the lost sensations
post hemiplegia.
However, its role in gaining back the lost motor functions post hemiplegia
has always been very controversial. Many physiotherapy clinics across the
globe freely use the faradic or the galvanic type of electrical stimulation regularly
on their patients. Sometimes, due to lack of time on the part of the physiotherapist
compeled to use the electrical stimulation more than the specialized techniques
of neurophysiotherapy.
While electrical stimulation may be effective in gaining the motor control
back as many studies suggest, its judicious use is strongly advocated. If electrical
stimulation is given wrongly, it may prove to be harmful rather than beneficial
e.g. faradic stimulation given to the flexor of the wrist and fingers and elbow
flexors may increase spasticity and complicate the case further and delaying
the recovery of the wrist and fingers extensors and elbow extensors, respectively.
Thus, electrical stimulation should be used cautiously and is to be used
as an adjunct to the neurophysiotherapeutic techniques and not as a replacement.
TENS and interferential current therapy are highly effective in reducing
the pain which is present in large numbers of the patients in shoulder region.
They are also effective in reducing the pain and improving the circulation
in the cases of shoulder hand syndrome. Interferential current therapy also
helps in influencing the sympathetic nervous system and hence, decreasing
the symptoms of the shoulder hand syndrome like burning, hypersensitivity,
pain, etc. TENS and Interferential current therapy help in reducing the dreadful
symptoms of the condition called Thalamic Pain Syndrome. They are effective
in reducing the discomfort resulting from the subluxated shoulder.
The sensory activation post stroke can be influenced positively by the use
of sensory amplitude electrical stimulation and neuromuscular electrical
stimulation in the early stages.
Thus, electrical stimulation is a good tool for gaining the motor control
and sensory activation in the patients suffering from hemiplegia if used along
with the neurophysiotherapeutic techniques, even in as chronic cases as five
years post stroke.
New researches are going on in the world in this field using different methods.
One of the methods is intracranial electrical stimulation, where, tiny electrodes
are placed on the brain and the part to be stimulated is triggered with external
unit. It is explained elsewhere in this thesis.
Another method is EMG triggered electrical stimulation in which, the sensory
electrodes are kept at the surface of the muscle to be stimulated, and, the
patient is asked to perform the task of that muscle. The signals of the muscular
contraction initiation are taken up by the machine via sensory surface electrode
and when the desired threshold is reached, the machine gives electrical
stimulation to that muscle to complete the movement. This method is unlike
the conventional electrical stimulation, which is passive in nature. Here, in
this method, the electrical stimulation of the muscle is only done when the
patient tried to perform the task of that muscle. Thus, it is an augmenter
of the patient’s own efforts and not a mere passive stimulation. The effectiveness
of this method is under scanner and hence, its results would be out soon.
At some places in the world, neuroprosthesis have been used, to a lesser
effect. They are devices to be fixed inside the nerves and they stimulate the
nerve when need be. The research on this topic is far too less to comment
upon.
One more method of stimulation is the functional electrical stimulation,
(FES), which is an effective way of gaining desired motor activity at a desired
time. The patient is fitted with the stimulator while engaging in the task
simultaneously. For example, the long extensors of the wrist and fingers are
stimulated for opening of the fingers while doing hand functions. The stimulation
is done when the patient attempts to open the fingers when need be to either
release the object or to grasp it. It can be effectively used while walking
when the muscles which are responsible for say dorsiflexion are stimulated
at the time of initial swing. The timing of the start of the impulse is highly
important in this technique.
ISOKINETICS
Isokinetic training may be used to improve
the timing of reciprocal movements of the
lower extremities required for gait. The
therapist should initially preset movements
to utilize slower speeds as control improves.
If consistency in maintaining a steady rhythm
is problematic, a metronome can be used
to pace the activity. With some types of
equipment, the patient’s position can be
modified to approach a more upright standing
position. A rate of movement approaching FIGURE 17.2: Isokinetic machines
1 cycle per second, which is within normal ‘primus’, right scapula dysfunction
(orthopedic case)
parameters for heel-strike to heel strike,
should be the desired end point of treatment.
Isokinetic training may also be valuable in stabilizer muscles of upper limb
(Figure 17.2). These muscles are difficult to rehabilitate but with the help
of isokinetic workout, this task can be simplified.
MUSIC AS THERAPY
Music can be of great assistance in gaining the rhythm of the movement.
Soothing music can decrease the spasticity in the muscles and improve functions
in the agonists. It provides a sense of general relaxation and global reduction
in the muscular tone. The pulse rate stabilizes and hence, the patient is able
to concentrate more effectively on the task at hand. Some ragas of Indian
classical music and rhythmic chanting of vedic mantras can influence the mind
and body complex of the individual and take them to a newer height. They
can increase the inner strength of the individual and help cope up with the
situation. These methods also relax the therapist and the work efficiency increases
with the decrease in stress levels. Music also provides with the entertainment
which is of vital importance for both the therapist and the patient.
EXERCISE CONDITIONING
Patients with stroke demonstrate decreased levels of
physical conditioning following periods of prolonged
immobility and reduced activity. The energy costs
to complete many of the functional tasks in their
daily lives are higher than normal owing to the
abnormal ways in which they perform these activities.
Many patients also demonstrate concomitant
cardiovascular disease and may be recovering from
acute cardiac events at the same time. These patients
can benefit from an organized exercise program to
improve cardiovascular fitness as part of their
rehabilitation. The geriatric survivor with FIGURE 17.3: Bicycle
compromised cardiovascular function can benefit ergometry for exercise
from an ambulation program regulated by signs and conditioning, left
symptoms of activity intolerance. Other stroke hemiplegia
survivors should be able to engage in a more
traditional exercise conditioning program (Figure 17.3).
To ensure patient safety, patient should receive a thorough evaluation before
starting a program. Adequate supervision, monitoring, and safety education
about warning signs for impending strokes and heart attack are also important
considerations. Considerations for prescription should be based upon individual
abilities and the interest of the patient. The components of an exercise program
should include type of exercise, frequency, intensity, and duration. Warm up
and cool down sessions should include stretching and strengthening elements
as well as aerobic elements of increasing or decreasing intensity, typical aerobic
elements include cycle ergometry of arm and leg, walking, and stair climbing.
A frequency of 3 to 5 days a week with an intensity of 60 to 85% of the
age predicted maximal heart rate, 50 to 80% of maximal oxygen consumption
or REPE (ratings of perceived exertion) value of 12 to 13 should provide
an adequate training stimulus. The duration will vary depending upon the
frequency and intensity of the activity. The use of training diary is an excellent
way to keep track of prescriptive elements, objective measurements (heart
rate, RPE, blood pressure), and subjective reactions (perceived enjoyment).
Conditioning programs for stroke patients can yield significant improvements
in physical fitness, functional status, psychological outlook, and self-esteem.
Regular exercise may also have the additional benefit of reducing risk from
recurrent stroke. Finally, patients who participate in a regular conditioning
program may more successful in adopting continuing, lifelong exercise habit
and in moving beyond the disabilities of the stroke.
ROBOTICS AND COMPUTER-AIDED THERAPY

The role of robotics and computer-aided therapy is a very novel concept
in the field of medicine and in the field of neurorehabilitation. As the studies
suggest, there is marked improvement in the arm functions after the use
of robot in the motor relearning post hemiplegia. It may take a while this
technique arrives in India but the advancement always brings about a radical
change in the way we look at the problem. The use of computers and its
feedback is also effective in gaining the motor functions post hemiplegia.
There are programs which help the patient use their paretic limbs more
effectively. The use of surface electrodes which are attached to the computer
show the contraction as the graphical representation on the screen. The patient
can thus follow the graph and the desired repetitive contractions can be
achieved. Virtual reality method which employs computer generated life-
like images in the controlled environment can be used as a precursor to
the functions in the actual environment. The patient first practices the functions
on the virtual images in the virtual world and then, the real world functions
can be safely started.
Other newer technique is stem cell therapy which is in its nascent stage.
The results of the same are eagerly awaited by medical persons as well as
general population equally.
CONSTRAINT-INDUCED THERAPY
Constraint therapy is a newer invention in the field of the rehabilitation of
hemiplegic hand. After gaining a reasonable motor recovery in the post
hemiplegic hand, most patients find it difficult to use their upper extremity
in activities of daily living. This is known as ‘learned disuse’ of the body
part. This occurs due to the inhibition of that specific part, here, the upper
extremity. To tackle this problem of learned disuse, the patients are well, almost,
forcibly made to carry out the active hand usage in a controlled environment.
The patients are kept in a room with minimum or no external disturbances
like sound or visual stimuli so that mental distraction is minimum and there
is full concentration in the task which is given. The normal hand is kept
in a splint so that they cannot use that limb and hence, cannot substitute
for the hemiplegic hand. The patient is given a series of tasks which are
ranging from simple prototype active movements of the hand to a more complex
set of activities of daily living. They are encouraged to carry out the same
with full zeal and force. The sessions are carried out for 5 to 6 hours a day,
3 to 4 times a week, and the progress is monitored every fortnight. Recent
studies have shown remarkable improvement in the functional ability in the
individuals with the problem of learned disuse in 3 to 4 weeks of time.
Limitations
This therapy can only be used in the individuals with some amount of active
motor control in hand. The patients many a times become irritable at the
limitations of their performance and get frustrated. In patients with gross
spasticity, the hypertonia increases in the entire body, rendering the therapy
useless.
MOTOR RELEARNING
Motor relearning is a technique developed in Australia and in the recent times,
a lot of studies are going on to find out the efficacy of the same in the
treatment of hemiplegia.
This technique concentrates on the fact that the repetition of the movements
produces the required memory anagrams in the brain and hence, the motor
function of the part improves. The patients with hemiplegia are made to do
the exercises a number of times a day till they become proficient in doing
the same. The numbers of repetitions are designed according to the tolerance
of the patient. Maximum numbers of repetitions are selected for each activity
and patient is asked to do the same several times a day. This treatment is
continued till the patient can easily perform the task assigned.
These exercises can be simple active movements of the joints in the acute
stage to progressing towards more complex functional activities including various
muscles and joints interplay.
HYDROTHERAPY
Hydrotherapy is a specialized approach of treatment for the patients suffering
from hemiplegia. As the name suggests, water is used for the therapy.
Hydrotherapy or exercises underwater use the principle of buoyancy of
water. The force of the buoyancy of water is the force which is opposite
to that of the force of gravity. If any object is placed in the water, the water
will exert the force of buoyancy on that object, in opposite direction to that
of the force of gravity. Thus, the effective weight of the body will decrease
when in water, as compared to its effective weight on land. Physiotherapy
also uses the force of buoyancy in the favor of the patient. If the hemiplegic
patient is placed underwater, the effective weight of the patient will decrease.
Thus, the patient will have to carry that much less load of the moving limbs.
When the limbs become light in weight, it is easier to move them. This will
ensure decreased effort on the part of the patient with increased efficiency.
The spasticity decreases with the decrease in the effort, which will in turn
improve the motor function.
Water is also a good tactile stimulator and hence, the sensory integration
can be carried out underwater effectively. Underwater exercises can be relaxing
and entertaining for most of the patients.
In the initial stages when the patient is unable to move by himself, the
patient is lowered in the water with the use of a waterproof plinth which
is lowered in the water by the use of chains attached to a pulley device.
For the safety, the patient is tied onto the plinth with the straps. The patient
is then asked to perform the movements underwater on the plinth itself keeping
the head and neck outside the line of water. The buoyancy of water will
provide assistance to the moving limbs if the movement is done against gravity.
This will register the movements in the brain in the antigravity direction which
is not possible for the patient in the initial stages. The endurance will improve
as the patient can perform the activities underwater for a longer duration than
on land due to weightlessness of the body.
In the later stages, more active protocol can be employed and the recovering
limbs can be subjected to resistance by the water itself if the movement is
made in the direction of gravity. Gait training can be done in the gravity
eliminated plane underwater, effectively.
Apart from the various advantages of the exercises underwater, there are
many disadvantages of the same. The temperature of the water should be
neither high nor low to accommodate the patient. The water should be very
clean so that the chances of cross infection can be avoided. The maintenance
for keeping the water warm and clean is too high for the most of the rehabilitation
clinics across India. The patient safety is also of a paramount importance
as one little negligence may prove extremely dangerous. A tie up with the
swimming pool can be done, but the unavailability of the trained staff and
the sadistic approach of the swimming pool attendants does not go in patient’s
favor and hence, the patient cannot be sent to the pool which is not run
by rehabilitation personnel.
A small effort on the part of the physiotherapy community with the help
from the local government and non-government organizations can solve the
problem of non-commissioning of the hydrotherapy units in India and the
patients can reap the benefits of exercising underwater even in our country.
ORTHOSIS IN HEMIPLEGIA
An orthosis is an external appliance worn to restrict or assist motion or to transfer
load from one area to another. Term orthosis appears to be since after World
War II. In case of hemiplegic patient orthosis are basically required when persistent
problems prevent normal and safe walking.
Factors Responsible for Using Orthosis

 Instability
 Weakness of ankle, foot, knee
 Extent of spasticity
 Sensory deficit of limb.
Types of Orthosis
 Temporary
 Permanent
 Static
 Dynamic.
Orthosis Used in Hemiplegic

Patients (Figure 17.4)
 AFO
 KAFO
 Wrist cock-up splint
 Pressure splints
 Air stirrup ankle brace
Functions of Static Splints

 It provides immobilization to the joint
 It maintains joint in correct alignment
preventing tightness, contracture and
deformity FIGURE 17.4: Note the use of
 It provides support and stability to the lax elbow extension splint, cock up
splint, AFO, right hemiplegia
joints
 It maintains the corrected or improved
ROM gained by therapeutic measures
 It provides stability to proximal joint to facilitate action of distal joint,
e.g. cock-up splint to stabilize weak wrist extension and to facilitate finger
flexion.
Functions of Dynamic Splint

 It provides resistance to tendons providing easy gliding, preventing adhesion
and stimulating circulation thereby, assist in reducing edema.
 It provides mobility to stiff joints by controlled sustained low load stretching.
Constant stretch lengthens shortened musculotendinous units and tight
articular structures as well.
 It provides re-education to weak or paralyzed muscles with synchronization
of active efforts
 It protects overstretching of weak muscles by strong pull of normal opposing
muscle group.
Static splints commonly used in hemiplegic are:
• Upper limb splints
– Cock-up splint
– Opponens splint
– Functional position splint

– Safe position splint
• Lower limb splint
– Posterior knee splint or cast
– AFO.
Dynamic splints commonly used in hemiplegic are
• Upperlimb splints
– Dynamic wrist flexion-extension splint
– Dynamic thumb splint
• Lowerlimb splints
– Dynamic AFO
– Dynamic KAFO.
Upperlimb Splints
Cock-up Splint
It maintains the wrist in 25–30 degrees of extension. In case of lack of extension,
control at MP joints, outriggers may be applied to make it dynamic, e.g. radial
nerve.
Opponens Splint
It maintains the web space of the thumb, thus holding the thumb in maximum
opposition.
Functional Position Splint

It is mainly a positioning splint,, maintaining flexion at MP and PIP joints
fixed at 40–50 degrees and the thumb in abduction and opposition.
Safe Position Splint

It is resting or positioning splint. The wrist is fixed in slight dorsiflexion, MP
joints in 90 degrees of flexion, PIP and DIP joints in neutral extension and
thumb is placed in abduction and opposition to allow ROM at the CMC joint.
The hand is safe from developing flexion contracture and to promote functional
use at larger stage. This is useful to prevent contractures following burns.
Dynamic Wrist Flexion-extension Splint

It allows both the movements of flexion and extension at the wrist with a
provision to maintain any of these movements fixed at desired range.
Dynamic Thumb Splint

A dynamic thumb splint can be fabricated as a low profile splint which keeps
the thumb in opposition, maintaining the web space.
Lowerlimb Splints
Posterior Knee Splints or Cast
It offers stability to unstable joints due to derangement; it facilitates the function
of weight-bearing and ambulation, the lower extremity splinting is in the form
of orthosis. It provides the needed functional stability to the unstable joint.
AFO
It consists of foundation, ankle control and super structure.
Foundation
Consists of shoe, plastic or metal component.
 Insert
– An insert or footplate foundation is used to provide best control of the
foot.
– Insert is usually used in shoes, close high on the dorsum of the foot
to retain the orthosis.
– Orthosis with an insert is relatively light-weight as it is made up of
thermoplastic material.
– It is appropriate if the shoe to be worn on orthosis is not of proper
heel. If the heel is low, upright will incline posteriorly , increasing tendency
to wearer’s knee to extend. If the heel is high, patient might experience
knee instability.
 Metal stirrup
– It is steel stirrup, U-shaped fixture riveted to the shoe through shank.
– A solid stirrup—maximum stability of orthosis on the shoe.
– A split stirrup—it is heavier than solid stirrup or the foot plate.
Ankle Control
To control ankle motion by limiting plantar flexion or dorsiflexion or by assisting
motion.
 Posterior leaf spring:
– It is used as dorsiflexion assistance arising from plastic insert.
– Upright is bend backwards slightly during early stance.
– During swing phase, plastic recoils to lift the foot.
– Narrow plastic permits greater motion.
 Klenzak joint—steel dorsiflexion spring assistance:

– The coil spring compresses during stance and rebounce during swing.
– Tightness of the coil can be adjusted but orthosis is noticeably bulkier
than post leaf spring.
– Both assistance will yield slightly into plantar flexion at heel contact,
affording the wearer protection against excessive knee flexion.
 Posterior stop—plantar flexion resistance:
– To prevent toe drag through plantar flexion resistance, preventing the
foot from plantar flexion so that during swing phase foot drag will not
occur to catch the toe and stumble.
– It imposes flexion over the knee during early stance and prevents lax
knee from hyperextending.
 Anterior stop:
– It limits dorsiflexion which helps during later stance.
– Plastic anterior spring extending from mid-dorsum of foot to proximal
margin of the orthosis.
 Plastic solid ankle foot orthosis:
– It limits foot and ankle motion
– It compensates for lack of plantar flexion in early stance.
– It may be divided into 2 section at ankle through hinged known as hinged
solid ankle-foot orthosis providing sagittal motion, achieving foot flat
position in early stance.
Super Structure
Uprights
 Solid ankle and hinged ankle AFO have posterior shell, extending from
medial to lateral midline of the leg, thus providing excellent medial lateral
control and broad surface to minimize pressure.
 Uprights have calf bands which must not impinge on peroneal nerve.
 Anterior band part of solid AFO imposes posteriorly directed force near
the knee, enabling AFO to resist knee flexion.
 Tone reducing orthosis in hemiplegics consist of foot plate and broad uprights
designed to modify reflex hypertonicity by applying constant pressure to
the plantar flexors and invertors.
Merits of AFO
 AFO is usually prescribed to control deficient knee and ankle foot function.
 Posterior leaf spring helps to control foot drop.
 Modified AFO has wider lateral brim and provide additional control of
calcaneal and forefoot inversion and eversion.
 Solid ankle-molded AFO helps in maximum stabilization through its wider
lateral trim lines.
 Posterior stop can be added to limit plantar flexion, with spring assist,
can be added to assist dorsiflexion.
 An ankle set in 5 degrees dorsiflexion limits knee hyperextension, while
an ankle set at 5 degrees plantar flexion, stabilizes the knee during mid
stance and prevents knee buckling.
Air Splints/Inflatable Pressure Splints

 It stabilizes and helps in maintaining the extremity in elongated position.
 Inhibition of tone, for example, spastic elbow flexors, is provided.
 Splints also helps in control unwanted associated reactions, and assist in
early weight-bearing.
 Patients with a flaccid, hypotonic limb benefit from the use of pressure
splints to provide increased sensory input. When used along with weight-
bearing, tone is facilitated.
 Long or full limb pressure splints also assist in controlling edema, a common
problem of paralyzed limb. Positioning with elevation is an important
consideration.
Demerits
Disadvantage of metal devices include heavier weight, less cosmetic appearance,
and increased difficulty in putting it on.
The type of orthosis may change with continuing recovery.
With limited reimbursement, ordering a new orthosis may create problems
and speak to the need to anticipate changes when ordering the device, its
change in prescription and discontinuing the use of the device.
Orthotic training includes donning and doffing instructions, skin inspections,
and education in safe use of the device during gait.
BOTULINUM INJECTIONS FOR SPASTICITY

Physical and occupational therapists play important roles in the evaluation
and management of patients receiving botulinum toxin type A (BTX) injections
for spasticity. Having a thorough working knowledge of this intervention will
allow therapists to refer appropriate patients for such injections. The sudden
decrease in muscle tone brought on by BTX enables the therapist to focus
on functional treatment goals and implement interventions quickly and
effectively.
Before BTX injection, patients need to be extensively evaluated by the
therapists to quantify baseline function for effective outcomes determination.
Since a decrease in spasticity in one area can precipitate functional changes

in other associated or unanticipated areas, the evaluation must include areas
beyond those being injected. After injection, and once the patient’s response
is ascertained, the evaluation may be modified for future injections to the
same region.
With patients affected by chronic spasticity, it is helpful to evaluate and
treat the patient as a “new” patient after injection. Injections will interrupt
synergistic patterns and affect neighboring or more distant muscle groups.
With local spasticity suddenly reduced, the patient may present with a different
clinical and functional picture and may be a candidate for therapeutic
interventions not previously possible. Motivated by the sudden decrease in
spasticity, patients frequently stop taking oral and antispasmodics despite previous
instruction to the contrary. Therapists need to reinforce that patients must
continue taking their medication until after post-injection assessment as directed
by their physician.
Evaluation
A patient receiving BTX should be evaluated thoroughly before the first injection.
The scales and techniques chosen can be adapted to either the occupational
or physical therapies, as well as to the type of clinical setting. Pre and post-
injection measurement consistency is essential for effective comparisons. Because
the measures themselves may influence tone during the clinical visit, it may
be important to run the testing series in the same order and position each
time. Below is a list of evaluation tools and techniques that are available
for the adult patient about to receive BTX treatment.
 Modified Ashworth Scale (MAS)
Performed for all muscle groups in the extremity with increased muscle
tone, whether these muscles will be injected or not. Spasticity reduction
in one area may affect muscle tone in neighboring areas, particularly where
synergies are involved.
 Pain Score
Executed for the entire extremity to be injected, as well as for the specific
region being injected. In left gastrocnemius injections for example, the lower
extremity is rated for pain, as in the left ankle region. The patient is asked
to rate the amount of pain in the affected region on scale from 1 to 13.
 Spasm Frequency (SF) Score
All muscle groups with spasm within the extremity to be injected are graded.
Spasticity and spasm reduction in one muscle group may result in a decreased
SF in neighboring muscles.
 Bilateral Adductor Tone

This measure is performed on all patients receiving lower extremity injections
who exhibit increased tone in the adductors of the leg. The assessment
is performed with the patient supine. The examiner abducts the legs
simultaneously and grades the amount of effort needed.
 Range of Motion (ROM)
ROM is assessed following the MAS assessment and measure of bilateral
adductor tone so as not to influence existing muscle tone. Active and passive
ROM is assessed goniometrically in the injected extremity. Consistency
should be maintained in order and position of assessment pre- and post-
treatment so as not to influence muscle tone or bias outcome assessment.
Positions can be modified, however, so as to evaluate the upper extremity
in sitting and the lower extremity in supine. This minimizes positional changes
that may influence muscle tone.
 Joint Resting Angles
Goniometric measurements can be taken of joint resting angles altered by
spasticity. Joint position may be noted in various functional positions, e.g.
sitting, standing, or immediately following ambulation. Documentation may
be supplemented with photographs or videotape. It should be kept in mind
that injections may interrupt synergistic patterns and reduce resting angles
at neighboring joints.
 Strength
Strength may be assessed in related areas where normal muscle tone is
present. The accepted method of assessment is conventional manual muscle
testing. The numerical scale used is a 6 point ordinal scale assessment
strength from 0 (no contractile abilities) to 5 (strength through the full
ROM with maximal resistance). Dynamometer testing can objectively
determine grip strength where normal muscle tone is present.
 Motor Control
Motor control is assessed where muscle tone is altered. Unfortunately,
standardized assessments for motor control that can be tested for validity
and reliability have yet to be devised for use in the neurologic patient.
Most available measures, including Brunnstrom and Fugl-Meyer, focus on
assessment in the post-stroke patient. These methods, which are not widely
used, are based on the premise that stroke recovery follows a predictable
pattern from reflex movement, to volitional movement within synergistic
patterns, and then to volitional movement out of synergy. Bobath’s method
grades the ability to move out of synergistic patterns as it relates to functional
importance.
When measured goniometrically, the previously described active movement

(active ROM) indicates available volitional movement. EMG evaluation
can document available active muscle contraction and may help indicate
the functional potential of opposing antagonists or neighboring muscle groups.
 Fine Motor Coordination and Dexterity
The score for the finer functions and dexterity of the hand should be taken
prior to the injections and timely evaluation of the same post injections
should be taken to find out the effect of the same.
Order for Evaluation of Muscles in the

Patient with Spasticity
Assessment in the patient with spasticity is complicated by the effect of the
evaluation procedures on muscle tone; the examination influences what it is
measuring. The proper order of evaluation can minimize this influence, and
performing the evaluation in the same order each time ensures consistency
of effect between successive examinations. Muscle tone is assessed before
any functional or other clinical assessments requiring movement or handling
of the patient. The upper extremity precedes the lower, right precedes left.
The upper extremity is evaluated in the sitting position. As indicated below,
the shoulder rotators, pronators, supinators, wrist flexors/extensors, and finger
flexors are assessed with the elbow in 90 degrees of flexion. Other muscle
groups are assessed with the elbow extended.
The following order of muscles may be considered:
With elbow extended, evaluate:
 Shoulder flexors
 Shoulder extensors
 Shoulder adductors
 Shoulder abductors
With elbow flexed, evaluate:
 Shoulder internal rotators
 Shoulder external rotators
 Elbow flexors (shoulder at 0 degree flexion)
 Elbow extensors
 Pronators (elbow flexed 90 degrees)
 Supinators
 Wrist flexors
 Wrist extensors
 Finger flexors
The patient is positioned in supine for assessment of all muscle groups

of the lower extremity except the knees flexors. The right side is assessed
first, followed by the left. The patient is then positioned prone for assessment
of the right, then the left knee flexors.
The following order of muscle may be considered:
Supine
 Hip flexors
 Hip extensors
 Hip adductors
 Hip abductors
 Knee extensors
 Ankle plantar flexors
 Ankle dorsiflexors
 Ankle invertors
 Ankle evertors.
Prone
 Knee flexors
The modified Ashworth scale assessment is executed first, followed by the
bilateral adductor tone measure, if required. Goniometric measurements for
active and passive ROM follow muscle tone assessment. All other aspects
of evaluation may then be executed. This specific order of assessment may
not fit all patients, therapists, or clinical settings. Of primary importance, however,
is that movement of the trunk and limbs be minimized when assessing tone
and that consistency be maintained between assessments.
 Balance Skills
Balance skills are assessed for patients receiving either upper or lower extremity
injections. One useful test, which has shown good inter-rater reliability and
validity, is the timed-up and go test, based on the initial get up and go test
developed by Mathias. The patient is asked to rise from an arm chair, walk
a line 3 meters across the floor, turn around, and return to the chair. The score
is given as the number of seconds it takes to complete the task. The patient
is allowed to wear his usual footwear and use his usual assistive device. This
test is easily performed in any clinical setting and has direct functional importance.
 Activities of Daily Living (ADL)
All ADL skills are to be assessed before either upper or lower extremity injections.
When appropriate, the caregiver may be questioned regarding type and amount
of assistance required by the patient. Aspects of the functional independence
measure (FIM) and the Barthel index may be used for grading ADL function.
The Barthel Index is a questionnaire aimed at the three functional areas of
self-caring (drinking, eating, grooming, dressing), bowel and bladder continence,
and mobility including transfers (chair, tub and toilet), ambulation and stairs.
Scoring is from 0, indicating total dependency, to 100, indicating total
independence. Snow and Tsui developed a “Hygiene Score” which may be
used for patients requiring caregiver assistance for perineal hygiene tasks.
This measure allows documentation of changes in the amount of assistance
required for complete care for patients receiving BTX injections in the lower
extremity. The Berg balance scale assesses balance in a variety of functional
skills and may be used to provide standardized functional data related to a
patient’s ADL abilities. This test scores 14 skills of a total of 56 points and
includes such tasks as transfers, getting in and out of a chair, aspects of standing
(stance and balance), forward reaching, and retrieving objects from the floor.
 Transfers
Transfers can be influenced by a reduction in spasticity and, therefore, are
assessed.
Effects and Benefits

The Botulinum toxin is injected in the spastic muscle for the reversible paralysis
of the spastic muscles. This will ensure the relaxation of the spastic muscles.
Due to spasticity, even the resting posture of the limbs is not correct and
if it is allowed to stay put same way, can lead to contractures and deformities.
The relaxation of the muscles will ease out the process of stretching of the
muscles and hence, prevent deformities. Hygiene of the part improves with
the improvement in the posture of the limb, e.g. hygiene of the palm in spastic
long flexors of forearm. The reduction of the spasticity of the agonists will
facilitate the recovery of the agonists and help in speedy recovery of the
patient.
Therapeutic Exercise
Das and Park, Dengler et al, Hesse et al., Dunne et al., Pierson et al., and
Yablon et al., all have conducted studies demonstrating improved active or
passive ROM following BTX treatment. Simpson et al. showed improved grip
strength following injections in the upper extremity hemiplegic stroke patient.
All investigators demonstrated decreased muscle tone in the injected muscles,
which has important implications for therapeutic exercise intervention. After
injection, a priority for therapeutic intervention is strengthening and facilitation

of the opposing and neighboring muscle groups. Treatment goals include
maximizing the patient’s abilities in the antagonists, to further reduce spasticity
are reciprocal inhibition and reinforce more normal mobility and position.
These muscles can be chronically over-stretched and atrophied from disuse,
and may be initially at a mechanical disadvantage after injection, requiring
a longer response time.
Once spasticity is decreased, stretching and flexibility exercises for the
spastic agonists may begin where indicated. New increases in passive or active
range of motion may be possible. This may enhance therapy participation,
function, or the execution of home programs by the patient or caregiver. In
spasticity patients, decreased mobility and abnormal movement patterns may
lead to under-stimulated proprioceptors and mechanoreceptors. Following
spasticity reduction, stimulation can be provided via weight-bearing activities,
vibration, proprioceptive neuromuscular facilitation, and a variety of other
techniques. Many patients may now tolerate developmental or Bobath type
activities that had not been possible before, such as quadruped and kneel-
standing. Benefit may also be gained from re-educating balance and stability
in such positions, as well as in standing and sitting.
The role of the injections is only to reduce the tone of the muscle and
this means that more work needs to be done before its beneficial effects reach
the patient. The assessment provides the background of the matter. After mapping
the muscle of the muscles to be injected, the patient is prepared. The patient
is informed regarding the merits and the demerits of the treatment and consent
for injecting is taken. The muscles are then marked and exact site of injections
is finalized. The toxin is diluted according to the dose suggestions and the
type of the muscle. The injection is then given intramuscular. It is advisable
that complicated and small muscles should be injected under the guidance
of Electromyography or EMG.
One week post-injections, the patient is kept in an immobilizer for a period
of 2 to 3 weeks. If the patient is uncomfortable with the immobilizer or if
it is contraindicated, the patient is advised to stretch the injected muscle frequently
throughout the day so that spasticity can reduce faster and relaxation and
newer resting length of the muscle is obtained.
Vigorous physiotherapy in form of stretching, facilitatory exercises, weight-
bearing and adjunct therapy are started immediately for many times in a day
and patient is taught the same. The peak effect of the injections is approximately
gained at one month and the effect lasts for about 4 to 6 months. There are
subjective variations due to the dose of the drug, its antibody formation in
the body, amount of stretching and physiotherapy. During this time, the patient
is instructed and motivated for complete cooperation in physiotherapy. The
injections can be repeated after the antibody response decreases in the blood
which is after a six months of time.
The effect of botulinum toxin is best got in the patients who have got
at least some amount of recovery in the agonist muscles. Otherwise, the spasticity
may decrease in the injected muscle, but patient may not get the desired motor
recovery and hence, may feel dejected and unsatisfied with the treatment.
OTHER ALLIED THERAPIES

In India, there are many systems of medicine which the patient undergoes
when ill. These are the allopathy, homeopathy, ayurveda and unani to name
a few. In today’s world, any system of medicine which is not Allopathy is
known as alternative medicine. But, this author differs from this general view.
The systems which are listed above are existing since many years and the
encouraging results and the scientific approach which they possess qualify
them to be known as ‘Allied Therapies’ and not ‘Alternative Therapies’. The
discussion of the importance of these therapies is way beyond the scope of
this study and hence, they will be enumerated below. It is the observation
of this author as well as many other clinicians practising for neurological
rehabilitation that the physiotherapy and rehabilitation has no alternative and
hence, all the patients should undergo rehabilitation programs regardless the
system of medicine they pursue. This will secure the patient of the basic
motor and sensory awareness and rehabilitation would be complete in nature.
List of Therapies
 Ayurveda
 Allopathy
 Homeopathy
 Unani medicine
 Aroma therapy
 Reiki
 Pranic healing
 Accupressure
 Accupuncture
 Color therapy
 Gem therapy
 Crystal therapy
 Water therapy
 Mud therapy
 Naturopathy
 Magnet therapy
 Psychic healing
 Doraa-dhaagaa
 Meditation
 Sujok therapy
 Medicinal oil massage and tissue manipulation
 Traditional system of medicines of adivasis
 Chakra balancing therapy
 Stone therapy
 Pendulum therapy.
The list is endless due to the extent in which the hemiplegic patient tries
to get the recovery from this dreadful condition. We respect all the methods
of the patient care but firmly advocate the judicious use of all these therapies.
The patient should be the central theme of the treatment and not the system
of medicine which the patient uses.
C H A P T E R
18
Hemiplegia Care at Home
INTRODUCTION
When the patient gets discharge from the hospital,
the patient may not be able to even turn to sides
actively. In such a case in India where rehab hospitals
are few in number, the patients are treated at home
(Figure 18.1). All the arrangements for the patient
care are done at the patient’s residence. Physiotherapy
services are arranged at the earliest on the reference
of the consultant. The patient, if affording, will have
the services of the nursing support staff. Sometimes,
if the patient is in a vegetative state, a separate room,
especially for the patient with the adjustable bed FIGURE 18.1: Assisted
and ripple or the air or water mattress is arranged gait training at patient’s
for. Physiotherapy is started at the home with the home, helped by relatives
available resources. Usually, it is the physiotherapist
who arranges for the required things. The therapist is the one who spends
most of the time with the patient and hence, in the initial stages, the therapist
becomes a clinical psychologist for the patient as well as the patient’s relatives.
Physiotherapist will educate the patient and the relatives regarding the importance
of rehabilitation.
MERITS OF HOME TREATMENT

There are some advantages of the patient being treated at home.
 The patient initially is very nervous and anxious and has just returned from
the hospital, which is a traumatic experience. After coming back to home
which is a familiar environment, the patient’s mood improves and it manifests
on his recovery.
Hemiplegia Care at Home 385
 The patient may be disabled physically and hence, may not have enough
strength for attending the physiotherapy and rehabilitation department.
Physiotherapy at home will provide the best solution for this problem.
 The physiotherapist would be treating only one patient at a time while at
patient’s home. This gives the therapist enough attention and focus on a
single patient only, which is mandatory for the patient in the acute stage.
 Home physiotherapy program is safer than the rehab department for the
patient in the early stages.
DEMERITS OF HOME TREATMENT

Where there are merits, there are bound to be demerits. The demerits of the
home treatment are as follows:
 If the patient is treated at home, lot of arrangements for the patient are
needed like the bed, mattress, physiotherapy and other rehabilitation services,
etc.
 For the physiotherapist, there are no equipments which may be useful.
 The patient does not go for the rehabilitation or for recreational outing
and will get confined to the home.
 The patient will not have contact with other patient of similar condition
and this will decrease the patient’s communication.
 Arranging everything for the patient is costly monetarily, for the relatives
of the patient.
 The patient may sometimes get used to confinement in the home and may
not like to go out and mix with people even if they are physically fit
to do so.
Brocklehurst suggested that social factors are the most significant elements
which influence the doctor in his decision to treat the stroke patient at home.
It has been claimed, however, that many doctors lose interest in the stroke
patient, once the acute phase of the illness has passed and that most patients
in the community receive very little, if any, long-term rehabilitation (Mulley
and Arie, 1978).
There are a number of approaches to the treatment of the stroke patient,
each with their enthusiastic advocates; here, we shall discuss different techniques
which are usually selected empirically and tailored to fit the needs of the
individual patient and his family. The methods used are similar to those employed
in hospital. Within the home, there are not the comprehensive facilities available
in hospital; this factor along with problems of space, equipment, old and infirm
relatives and unsuitable beds all create special challenges for the domiciliary
physiotherapist when treating the stroke patient at home.
TREATMENT PLAN
Before treatment commences, it is essential that a plan is prepared with a
detailed assessment of the patient including physical dependency, communication
problems, mental state, social background and medical diagnosis.
This initial record can be based on a number of different functional tests.
No particular system of recording is wholly satisfactory and there is no general
acceptance among physiotherapists as to which is most suitable. The ideal
system needs to be easy to complete, simple, and reproducible by different
physiotherapists on the same patient. The importance of accurate recording
cannot be overstated.
As well as this initial assessment, there should be a continuous monitoring
of progress, by a physiotherapist in order to have an unbiased assessment
of the patient’s achievement.
PROBLEMS ASSOCIATED WITH HOME-

BASED TREATMENT
These can be considered under a number of headings which are not listed
in any order of importance as the circumstance may alter from patient-to-
patient—psychological, social environment, equipment, communication,
diagnosis, supporting, services.
Psychological Problems
Following hemiplegia, a major problem can be depression which may be severe,
and long-standing. Lipsey et al. (1984) estimated that depression can affect
between 30% and 60% of post-stroke patients. It is, therefore, essential that
the domiciliary physiotherapist is aware of the signs and symptoms of depression
so that the concerned doctor is alerted.
It will be appreciated that an affective disorder such as depression involves
an increase in intensity of normal emotions and that the boundary between
normal and abnormal is imprecise. There are certain behaviors that are
characteristic of the depressed state:
1. Depressed mood: The major complain in most cases. This state is reflected
in the posture, facial expression, speech and general appearance of the
patient.
2. Difficulty in sleeping: Either difficult to get to sleep or early morning
awakening, there may be a loss of the sleep architecture in many of the
patients. The ratio of the REM and NREM sleep patterns change.
3. Loss of energy: Patient feels tired and drained, may even imagine he has
some serious disease.
4. Loss of interest: Patient loses interest in work, home, social activities,
sex.
5. Loss of concentration: Patient is unable to concentrate, memory is unreliable.
Pre-occupation with morbid self-doubt or guilt feelings.
6. Loss of appetite: Most patients lose their appetite, although younger people
may over eat as a compensation for feelings of inadequacy.
Transference is a term used to describe the development of an emotional
attitude in a patient towards a therapist. It is not unusual for a patient to
experience powerful feelings of love, hate and so on with regard to the
physiotherapist. The patient may also have certain fantasies about the
physiotherapist and it is important that the therapist is able to appreciate that
such events are a normal consequence of many therapeutic relationship.
Apart from the psychological problems experienced by some hemiplegic
patients, there are also psychological problems for the physiotherapist when
faced with a large contingent of such patients in the community. The work
is usually heavy and demanding both in terms of time and effort, with the
likelihood of emotional demands on the physiotherapist which are, on occasions,
more exhausting than their physical counterparts.
The fact that the majority of the stroke patients are aged 65 and over adds
additional stress, as many patients of this age are suffering from more than
one pathological condition or present with a serious social problem, unconnected
with the stroke.
As the domiciliary physiotherapist is working in comparative isolation, it
is probable that the therapist is faced by more difficulties and the need to
accept more responsibility for the patient than other medical staffs.
Social Problems
In the hospital, the patient is a part of a process which ensures that patients
are fairly strongly regimented with regard to their treatment. If a physiotherapist
shows the ward staff how to position the patient in a certain way, this will
usually be implemented whether the patient is able to agree or not. In the home,
the roles are reversed—the physiotherapist is a guest and if the patient does
not wish to comply with the treatment procedures, he may refuse. It is vital
that the domiciliary physiotherapist should gain the confidence and cooperation
of the patient and his family, as early as possible, in the treatment course.
The physiotherapist will be teaching the family certain exercises and routines.
In such a situation, it is not unusual for the physiotherapist to be seen as
part of the family and professional standing of the physiotherapist should

be retained in order that role boundaries do not become unclear.
In dealing with any patient, a friendly reserve should be adopted and it
should be remembered that the dividing line between normal professional concern
and friendship is easily misread. Making friends with a patient can lead to
worry or even guilt; it is important to remember that some patients will
misinterpret sympathy or similar attitudes which can lead them to develop
unrealistic expectation about the clinical interaction. In this context, ‘friend’
is taken to mean a person with whom a mutual need of satisfaction can be
realized. It is reasonable for the physiotherapists to express hopes, values
and so on and to give support to the patient but the clinical interaction should
not be used to support or satisfy own needs or anxieties.
Problems with the Environment

The treatment of the hemiplegia patient will normally require very little
equipment. The main item of equipment missing in the home is a set of parallel
bars, a vestibular ball and a high mat. It is often difficult, if not impossible,
to get elderly person with hemiplegia down on to the floor and the appropriate
treatment will therefore, be given while the patient is on his bed. Tables or
chairs can sometimes be substituted for the parallel bars. Full length mirrors
are not always available in the home but lengths of mirror which can be
screwed to the wall can be obtained quite cheaply and are well worth the
investment.
With an efficient community store, there should be few problems with aids
such as chairs, commode, bath seats and transfer boards and so on.
Communication Problems
As physiotherapist is working single-handed within the community, it is probable
that the therapist will experience problems arising from extended or non-existent
lines of communication. To establish lines of communication is hardwork and,
initially, can be very time-consuming. These lines of communication are well-
established within the hospital but, in many areas, may be virtually unknown
within the community. The general practitioner (GP), nurse may have established
communication procedure but often the physiotherapist can find the self-having
to contact these individuals separately which can prove both difficult and
frustrating. Message left with a third party are rarely delivered correctly and
the domiciliary physiotherapist may have no option other than to spend months
establishing effective lines of communication with the colleagues in the
community.
Diagnosis
Quite often the diagnosis which the domiciliary physiotherapist receives may
be no more than telephone message saying ‘Mr X, CVA, please treat’. There
are always exceptions, but sometimes, it is difficult to contact the doctor on
the day when he is needed. The establishment of group practices adds to
this problem as some doctors may work only on certain days in the practice
and cannot be contacted.
An additional task which, increasingly, is allotted the domiciliary
physiotherapist is the request from a consultant for the opinion as to whether
the patient requires hospital admission for rehabilitation. This type of work
is an example of the role extension possible within the community and adds
greatly to the challenge presented by this type of work.
Supporting Services
Often the physiotherapist is the first person to recognize a particular need
in a family and then the therapist is faced with how to arrange for certain
supporting services for the patient and his family. In areas, where there is
no community, occupational therapist, the physiotherapist may have to request
for alterations to be made within the home. This is an area of responsibility
which ought to be extended to domiciliary physiotherapist who is trained to
recognize such a need and, more importantly, probably one of the first experts
to visit the patient.
SUGGESTED SOLUTIONS
All the above problems can be alleviated, if not prevented, provided a number
of basic steps are taken at the commencement of treatment. If the preparation
of the treatment plan, following the initial visit, is based on the problem-
oriented assessment approach, this will allow the various problems to be listed
in order of importance and enable the physiotherapist to define the role with
regard to each separate problem. In this way, the total problem presented
by any patient can be broken down into separate tasks, some which are the
province of other specialties, and this will prevent the physiotherapist from
attempting to do too much for any patient. The domiciliary physiotherapist
will often be faced with a ‘problem patient’ who is excessively demanding
of difficult. It is probable that the same patient is just as much a problem
for the doctor or the nurse as is for physiotherapist. The sense of isolation,
which is sometimes experienced by the domiciliary physiotherapist, can be
helped by regular attendance at the weekly meetings and by regular visits

to the consultants. Many consultants meet at intervals to hold clinical discussions.
Such meetings are worth attending. The social atmosphere encourages a good
working relationship between the disciplines. Many consultants welcome the
physiotherapist’s call at their clinic when they are more than willing to discuss
the patient and compare notes.
PHYSIOTHERAPIST
The routine which is adopted for the patient nursed at home is broadly similar
to that used in hospital. The extension of physiotherapy into the community
has enabled many stroke patients to remain at home and there is evidence
to suggest that patients receiving their rehabilitation at home, recover equally
well as those treated in the hospital. In hospitals which do not have a stroke
unit, there can be difference of expertize within the different wards and it
is sometimes difficult to engage the cooperation equally of all ward staff.
In this respect, the domiciliary stroke patient is at an advantage as provision
of care is directed and monitored by the domiciliary physiotherapist.
Early Stages
Treatment will begin as soon as possible, following the hemiplegia and will
include positioning, passive movements and care of the chest. The domiciliary
physiotherapist will have access to intermittent positive pressure breathing
(IPPB) machines, ultrasonic nebulizers and chest suction equipment; if required
can also arrange the supply of a tipping frame. If there is a chest infection
present, it is possible for the therapist to visit the patient frequently during
the early stage of recovery.
A full range of passive movement should be given each day and the relatives
will be shown these routines. Positioning of limbs should be taught and it
is helpful to fix diagram or pictures of the correct positioning above the patient’s
bed. Relatives are usually most anxious to be of assistance at this stage of
rehabilitation and time spent in careful teaching is well-rewarded.
It is important to remember that edema of the hand is found in 16% of
all hemiplegia patients; it is due to insufficient drainage from the lymphatic
and the tendency for patients to forget the arm, allowing it to hang over
the side of a chair. Passive movement and ultrasound can be used to eliminate
this edema which, if left, can rapidly become organized due to its high protein
content (Howell, 1984).
Positioning
Co-operation between the physiotherapist and the nurse is essential to ensure
that the patient is placed in the correct position following routine nursing
procedures. It is also important that the relatives receive consistent advice
from both professions as there is nothing as detrimental as conflicting instructions.
It is essential that the nurse and the relatives are shown how to lift the
patient up and down, and in and out of the bed. It must be repeatedly stressed
that they should not support him underneath his affected arm as this can lead
to the painful shoulder syndrome commonly found in the stroke patient. Provided
the nurse, physiotherapist and family work closely together, it is possible to
give a consistent service to the patient in the home.
Bridging
This simple procedure, which is taught to the patient and to his relatives
from the earliest possible time following his stroke, makes it much easier
to manage the patient in bed and facilitates such nursing procedures as sheet
changing, care of pressure areas and use of the bedpan.
Rolling
The ability to turnover in bed indecently provides considerable stimulus to
the patient and will contribute to an improvement in his morale. When it
is appreciated, many stroke victims suffering from depression which is often
linked with the inability to move without help, it can be seen that any independent
movement will be important to the patient.
Bridging and rolling can be taught easily to the relatives and their use
will make nursing considerably easier in the early stage of recovery.
Exercise Routine
The program of exercise will closely follow that outlined previously, although
there may be occasional modifications depending upon the time available to
the physiotherapist. Many of the procedures can be broken down into sections
and then taught to the relative, for example re-education of balance can be
taught in sequence starting with head control and progressing to the other
elements descried. It is possible for most relatives to cope with this ‘sectionalized’
approach and it ensures that the patient will be given a continuous and consistent
treatment, even if it should be spread over a longer period with less direct
professional input. The programmer of exercise assumes a bilateral approach
to the restoration of function which constantly reinforces the awareness of

the affected side. In the community where the patient is either too old or
too frail, his relative(s) is/are incapable of cooperating in the rehabilitation,
the method adopted may have to concentrate on making the patient mobile
by using the support of a walking aid, perhaps utilizing some form of knee
brace, such as the Swedish knee cage, or an ankle support.
The resulting pattern of walking is cumbersome and effectively prevents
a retune to independence as the patient can never carry anything or, while
standing, manipulate any utensil. There may be occasion when the use of
a below knee leg iron is justified, especially in cases where the patient is
unaware that the ankle is inverted and suffering repeated minor trauma.
Walking
When the patient achieves reasonable standing balance, walking can be attempted
even before he has mastered the ability to swing his affected leg. The timing
of this event will depend upon a number of factors including the morale of
the patient and his family, his walking pattern and the space available within
the home.
Advice
It is recognized that the patient and his relatives will seek advice from the
physiotherapist at all stage of his recovery. It is probable that the domiciliary
physiotherapist is the person with whom the patient most readily relates and
from whom advice most often will be sought. The advice which the
physiotherapist is expected to provide is wide-ranging and the therapist should
beware of offering advice which is contradictory to that of the other professionals
calling on the patient.
As far as advice on physical exercise is concerned it is probable that the
physiotherapist is the person most suitable to provide it. In cases where advice
on medication, social or psychological matters is required, the doctor or the
social worker can be approached by the physiotherapist and asked for their
opinions. It has been found that the patient is more likely to talk with the
physiotherapist than most other professionals, possibly because of the special
bond which develops during the course of treatment.
A delicate area is that of sexual activity. There have been a number of
instances where a stroke patient has suffered a second one following such
activity. Physiotherapists are often asked for their advice on whether such
normal pursuits should be attempted. The fact that the patient should ask
for advice of this nature suggests he should be encouraged to follow his desires,
as the object of treatment is the restoration of function where possible. It
is helpful to be reminded that doctors, when faced with similar questions,
are no more experienced than most physiotherapists.
Factors which Influence Recovery

Patients who recover their muscle function within the first 2–3 weeks can
be considered to have good prognosis for rehabilitation. Neurological recovery
is thought to begin at some point between the first and seventh week following
the onset of the hemiplegia, with little neurological improvement following
the 14th week. Functional recovery is closely linked with neurological recovery;
it has been suggested that much of the early recovery including that of the
upper limb, may be due to the restoration of circulation to ischemic areas
of the brain with late recovery attributable to the transfer of function to
undamaged neurons (Tallis, 1984; Thomas, 1984). One finding suggests that
improvement can occur in performance 2 years after the stroke (Langton-
Hewer, 1979). Factor which militate against recovery include severe spasticity,
loss of sensation and mental confusion with inability to cooperate with the
rehabilitation exercises. This author has managed to see the recovery of post
stroke hemiplegia after 10 years with proper physiotherapy in three to four
cases.
The attitude of the relatives within the home is most important. Patient
with many of the problem listed above can be maintained at home provided
there is good family support. Such families will require long-term support
from the domiciliary physiotherapist and it is common practice to keep such
patients on the list of regular visits for periods of three more years. There
may not be any physical improvement in such cases but the weekly or fortnightly
visit by the physiotherapist has been shown to be a significant factor in keeping
the seriously impaired stroke patient at home. Any claim that the recovery
of the stroke patient can be attributed mainly to circulatory and neurological
factors can be questioned by examining a stroke patient who has been neglected
for some reason. His limbs will be fixed in abnormal positions; contractures,
pressure sores and incontinence will complete the picture and will all contribute
to a severe nursing problem. The psychological state of the patient is an important
factor in recovery and the sudden change in physical circumstance will,
depending on his personality type, lead to depression or anxiety. The patient
will worry about his future, especially with regard to his work and finances,
and married patients may be concerned about a possible loss of attractiveness
where their partner is concerned. All of these worries will depend upon the
ability of the patient to be aware of his condition and are absent in a patient
suffering from anosognosia. When these worries are superimposed upon either
a speech defect or a perceptual difficult, the physiotherapist needs constant
patience and the ability to give continual reassurance.
Most physiotherapists will have had experience of a hemiplegia patient
who has been excessively agitated or who has struck out at them. These patients
are depressed and it should be remembered that this depression is natural
and, when the patient adjusts to his changed condition, should improve within
a few months. However, in one study, two-thirds of patients who were depressed
at the initial evaluation remained so seven to eight months later (Lipsey et
al, 1984). The best therapy is improvement and any change for the better,
no matter how minimal, must be highlighted by profuse praise and
encouragement. There can also be a loss of self-esteem with a refusal to accept
a changed body image, is anything to the extent that the patient will deny
that there is anything wrong with him. This state of mind is a serious impediment
to progress and the use of portable video equipment may help the patient
to adjust his self-concept.
The domiciliary physiotherapist must be able to advice on dressing, and
in so doing must remember that attempts at dressing with a paralyzed side
will involve twisting movement which can, in turn, cause muscle strain with
subsequent pain. Cooperation with the occupational therapist over such matters
as how best to put on socks, stockings, trousers, as well as what dressing
aids are available, is to be recommended most strongly.
Toilet problems are common; one useful hint is to place a small table by
the lavatory pedestal to hold sheets of loose toilet paper. Although washing
is often difficult, self-help must be encouraged. A bath seat is essential, and
support rails and uprights can be obtained by the relatives. Patients can be
taught to dry themselves by using several small hand towels rather than a
large bath towel which would be difficult to handle.
The economic, social and emotional effects experienced by the family as
a result of stroke may be expressed in feelings of helplessness and frustration,
often projected on to the physiotherapist in the form of criticism or by excessive
demands for additional treatment. To counter this, family should be involved
in all stages of the rehabilitation and should be encouraged to express their
fears and anxieties. The family should also be prepared for the eventual
termination of physiotherapy treatment and this process should commence from
the first visit. The house-bound stroke patient is not able to mix with other
stroke patients as is possible in hospital; such mixing in the ward encourages
social skills and will facilitate interaction among the patients. In the case
of the stroke patient at home, the physiotherapist will have to ensure that
this element to rehabilitation is not overlooked and the therapist may have
to advise the family how best to achieve it. The tendency for the family to
be protective and over-indulgent to the patient needs to be guarded against.
Although recovery is ultimately dependent upon the underlying pathology,
it is evident that the sooner the treatment begins, the better the outcome.
The age of the patient is not significant although it has been claimed that
the younger patient will have a stronger motivation to get better. Elderly patients
are as likely to respond as well to treatment as younger ones.
Severe spasticity if present, may be helped by drugs or by various surgical
procedures, while muscle weakness in sometimes treated by electrical stimulators,
such as the peroneal stimulator used in cases of foot drop. The painful shoulder,
common to many stroke patients, is a constant problem for the domiciliary
physiotherapists. It can be treated with positioning, ice, heat, interferential
therapy or ultrasound. Connective tissue massage is useful in domiciliary
treatment, while support from slings or the use of figure-of-eight bandages
may provide some relief. Maitland mobilization can be effective. In some
units, biofeedback has been used with varying degrees of success (Williams,
1982).
Discharge
There are certain guidelines governing the discharge from treatment of the
stroke patient, and these include:
1. Pressure of new referrals
2. The wishes of the patient and his family
3. Level of progress
4. Availability of follow-up services
5. Lack of further improvement.
For physiotherapists, the lack of progress is likely to be the point at which
discharge from treatment is considered. It should be remembered that the idea
of ‘discharge’ is stressful for the patient and his family may respond by demanding
further treatment, convinced that improvement will occur. Emotional language
if often employed: ‘left to rot’, ‘thrown out’ commonly being used to express
the fear felt at such a time. Because the domiciliary physiotherapists are often
required to face this situation alone, the therapist can experience acute discomfort
and personal feelings of guilt. In order to avoid such problems, it is essential
that the family is prepared for eventual discharge from the very first visit.
This will require continual reinforcement on each subsequent visit and a possible
routine is suggested:
1. Explain the nature of the illness and the possible plan of treatment.
2. Reassurance regarding the provision of other supporting services.
3. Praise and encouragement for the relatives.
4. Provide some indication regarding the probable number of weeks’ duration
of treatment.
5. This routine should be repeated on each visit so that the family is conditioned
to expect the eventual termination of treatment. There may be cases where
treatment will continue indefinitely on a restricted basis as described earlier.
As soon as the patient is able to walk upto the door, the encouragement
is made to take the patient out of the home as soon as possible. The patient
can practice the walking in the surroundings with the home-visiting
physiotherapist initially and then by themselves with the help of the relatives
or professional help. The patient can go out for the recreational activities
and the problems encountered are listed. These problems are discussed with
the physiotherapist and solution for the same is found out. The patient may
start going for physiotherapy in the clinic as soon as possible. This will decrease
the cost of the rehabilitation in a longer run. If the patient is affording, twice
a day exercise protocol is used where, once the patient goes to the clinic
and second time in the day, the physiotherapist would go for their home visits.
As patient become more and more independent, the home visits should be
stopped and the patient is advised to use the time for their professional activities.
The patient is taught to become independent of the physiotherapist so that
the treatment protocol is followed even in their absence. Many a times, young
physiotherapists migrate to foreign countries for better future and in turn,
jeopardizing the future of the patient. The patients usually get attached to
a physiotherapist who has treated him in the acute stages and with the therapist
leaving the patient; the patient will feel lonely, left out and insecure. So,
it is a duty of the therapist to see that the proper rehabilitation is carried
out in their absence; whether the patient is shifted to clinic for better functioning,
or the therapist migrating to some newer venues.
In social country like India, the strong social backdrop is a double-edged
sword. The relatives of the patient can become extremely cooperative at some
stage with the therapist and the patient and they can also become hostile
with the therapist and the patient at other stage. The therapist, therefore, should
gauge the social vibes of the patient’s environment and find out a suitable
way of treating, dealing and communicating.
Orthopedic Management of Stroke 397
C H A P T E R
19
Orthopedic Management of
Stroke
INTRODUCTION
The orthopedic management of stroke can be divided into three distinct time
periods:
1. Period of acute injury
2. Period of physiologic recovery
3. Period of functional adaptation to residual deficits.
The Period of Acute Injury
Initial efforts should be directed toward the medical stabilization of the patient.
The orthopedic surgeon is rarely involved in the acute care of the stroke
patient. In some situations, the orthopedic surgeon may be asked to assist
with splinting extremities to prevent limb deformities.
The Period of Physiologic Recovery
Spontaneous neurologic recovery occurs primarily during the first 6 months
following a stroke. This is particularly true for recovery of muscle function.
During this subacute phase, limb flaccidity changes to spasticity. When spasticity
becomes pronounced, temporary measures are used to prevent contracture taking
place. These measures are used till spontaneous neurologic recovery is taking
place.
The Period of Functional Adaptation to Residual Deficits
Generally, the patient is neurologically stable after 6 months. Decisions can
then be made regarding surgery to correct limb deformities and rebalance
the muscle forces. This is the time of greatest contribution by the orthopedic
surgeon.
EVALUATION
Improving extremity function requires detailed evaluation of all factors causing
the impairments.
Assessment of Cognition and Communication

An evaluation of cognition and communication skills is done during the physical
examination. The patient must be capable of following simple commands and
should also be able to cooperate with a postoperative therapy program. In
addition, the patient should have sufficient cognition to incorporate the improved
motor function into their use of the extremity. Adequate memory is needed
to retain what is taught during postoperative therapy.
Sensory Evaluation
Intact sensation is essential to functional use of the hand. The basic modalities
of pain, light touch, and temperature must be present. Two-point discrimination
is a valuable predictive test. A patient rarely uses the hand for functional
activities, if the discrimination is greater than 10 mm. Proprioception and
kinesthetic awareness of the limb in space are also important. Kinesthetic
awareness is tested in a hemiplegic individual by placing the spastic limb
in a position and asking the patient to duplicate this position with the sound
limb while keeping the eyes closed. Stereognosis is not a practical test in
spastic patients. They lack the fine motor control necessary to manipulate
an object in the hand. It is helpful to observe the patient’s spontaneous use
of the hand. Visual perceptual deficits add increased problems involving motion
of the limb and even awareness of the limb itself.
The ability to maintain balance and ambulate depends on adequate sensation
in the foot and ankle. The basic modalities of light touch and pain sensation
are essential. Proprioception must be present at the level of the ankle joint
for good balance reactions.
Evaluation of Motor Control, Spasticity and Contracture

In a neurologically impaired patient, it is frequently difficult to distinguish
between the many potential causes of limited joint motion. The possibilities
include increased muscle tone, a myostatic contracture, lack of motor control,
or the lack of patient cooperation secondary to diminished cognition.
Evaluation focuses on the following characteristics of the involved muscles:
voluntary or selective control, spasticity and contracture.
Ask five specific questions:

1. Does the patient have voluntary control over a given muscle?
2. Is the muscle spastic to passive stretch?
3. Is the muscle, as an antagonist, activated during active movement generated
by an agonist?
4. Does the muscle have increased stiffness when stretched?
5. Does the muscle have fixed shortening (contracture)?
When many muscles cross a joint, the characteristics of each muscle may
vary. Because each muscle may contribute to motion and movement of the
joint, information about each muscle’s contribution is useful to the assessment
as a whole. Treatment depends on such information
Spasticity often masks underlying motor control. First, establish passive
range of motion of each joint. Test by slow extension of the joint to avoid
the velocity-sensitive response of the muscle spindle. When spasticity is
significant and passive joint motion is incomplete, it is necessary and advisable
to perform an anesthetic nerve block to assess whether a myostatic contracture
is present. Alternatively, examine the patient under general anesthesia.
The degree of spasticity within selected muscles can be graded clinically
in response to a quick stretch as mild, moderate, or severe.
Motor control can be graded in the extremity using a clinical scale. The
extremity may be hypotonic or flaccid and without any volitional movement
(grade 1). A spastic extremity may be held rigidly without any volitional or
reflexive movement (grade 2). Patterned or synergistic motor control is defined
as a mass flexion or extension response involving the entire extremity. This
mass patterned movement may be reflexive in response to a stimulus but
without volitional control (grade 3). It is also possible for a patient to initiate
mass patterned movement volitionally (grade 4). Although patterned movement
can often be volitionally initiated, it is a neurologically primitive form of
motor control and of no functional use. Selective motor control with pattern
overlay is defined as the ability to move a single joint with minimal movement
in the adjacent joints when performing an activity slowly (grade 5). Rapid
movements or physiologic stress make the mass pattern more pronounced.
Selective motor control is defined as the ability to move a single joint or
digit volitionally independently of the adjacent joints (grade 6).
Grade Motor Control Features
1 Flaccid Hypotonic, no active movement
2 Rigid Hypertonic, no active movement
3 Reflexive mass pattern Mass flexion or extension response to
stimulation
4 Voluntary mass pattern Patient initiated mass movement

5 Selective with overlay Slow volitional movement of individual
of mass pattern joint. Stress results into mass action
6 Selective Volitional control of individual joint
Identifying Functional Problems and Cause of the Problems

Treatment is most effective when functional problems are formulated and
described in focal rather than diffuse terms. Treatment of focal problems lends
itself well to surgical intervention, which can target particular muscles. Surgical
lengthening, transfer, or release of targeted muscles can provide very effective
solutions to problems of function that are clearly identified from the outset.
The localizing approach is useful because it forces the clinician to indicate
the desired outcome in advance. The outcome is based on an analysis that
identifies the specific spastic muscles responsible for the problem. For example,
if the clinical problem is an equinovarus foot that inhibits walking, surgically
lengthening or transferring the tibialis posterior will not solve the problem
if tibialis anterior and gastrocsoleus muscles are really the culprits responsible
for the problem. Identifying the specific offending muscles is critically important
to localized strategies of intervention.
MANAGEMENT OF SPASTICITY DURING THE

PERIOD OF PHYSIOLOGIC RECOVERY
During this phase of recovery, limb flaccidity changes to spasticity. When
spasticity becomes pronounced, temporary measures are used to prevent
contracture formation. The treatment of spasticity depends on the time, since
injury and the prognosis for further recovery. In the period of physiologic
recovery, temporizing interventions are used because interventions which cause
permanent changes may result in chronic imbalance of forces across joints.
Oral Agents
Oral antispastic agents may be used during this period. Antispastic agents
that have sedating properties, such as baclofen, diazepam, and clonidine, may
compromise patients with attention deficits or memory disorders. Even a drug
such as dantrolene sodium, which has a peripheral mechanism of action, may
also cause drowsiness. Other serious side effects such as hepatotoxicity can
occur. Continuous infusion of intrathecal baclofen has been reported to be
useful in managing spasticity secondary to spinal cord injury but its role in
spasticity due to stroke is not very well studied.
Focal Treatments
Focal injection with neurolytic or chemodenervating agents is the most suitable
approach for treating restricted motion secondary to spasticity. Neurolytic agents
such as phenol and chemodenervation agents such as botulinum toxin A are
used during this period because their effects are temporary, lasting only 3
to 5 months. These agents are used when restricted motion occurs as a result
of focal spasticity. When these agents wear off the patient is re-evaluated
to determine whether additional recovery has taken place and whether there
is further indication for repeating the treatment.
Phenol Blocks
Phenol, a derivative of benzene, in aqueous concentrations of 5% or more
denatures the protein membrane of peripheral nerves. When phenol is injected
in or near a nerve bundle, its neurolytic action on the myelin sheath or the
cell membranes of axons with which it makes contact serves to reduce neural
traffic along the nerve. The onset of the destructive process with higher
concentrations of phenol may begin to show effects several days after injection.
The denaturing process induced by phenol extends biologically on the order
of weeks but eventually regeneration occurs. A phenol block is used as a
temporizing measure rather than a permanent intervention. The effect of a
phenol block typically lasts 3 to 5 months.
It has been shown that phenol destroys axons of all sizes in a patchy
distribution but more on the outer aspect of the nerve bundle onto which
the phenol is dripped. When phenol is percutaneously injected, it is likely
that the nerve block will be incomplete. This is especially useful in situations
in which a spastic muscle also has volitional capacity, because under these
circumstances, it is desirable to reduce spasticity while still preserving volitional
capacity of a given muscle or muscle group.
The technique of phenol injection is based on electrical stimulation. Motor
branches are injected close to the offending muscle or muscle group. These
branches are referred to as motor points. A surface stimulator is briefly used
to approximate the percutaneous stimulation site in advance. A 25-gauge Teflon-
coated hypodermic needle is advanced toward the motor nerve. Electrical
stimulation is adjusted by noting whether muscle contraction of the index
muscle takes place. As the electrode gets closer to the motor nerve, less current
intensity is required to produce a contractile response. The motor nerve is
injected when minimal current produces a visible or palpable contraction of
the muscle. Generally, 4 to 7 mL of 5% to 7% aqueous phenol is injected
at each site. Care must be taken not to inject the agent into a blood vessel;
this is done by aspirating before the injection.
Botulinum Neurotoxin A (BoNT-A)

BoNT-A is an agent used in the localized treatment of spasticity. Ordinarily,
an action potential propagating along a motor nerve to the neuromuscular
junction triggers the release of acetylcholine (ACh) into the synaptic space.
The released ACh causes depolarization of the muscle membrane, activating
a biochemical sequence that leads to muscle contraction. BoNT-A is a protein
produced by Clostridium botulinum that inhibits this calcium-mediated release
of ACh at the neuromuscular junctions. A 3–7 days delay between injections
of BoNT-A and the onset of clinical effect is typical. Effects are not seen
immediately by the patient, and usually a follow-up visit is arranged to check
the result. The clinical benefit lasts 2 to 4 months but may be more variable.
BoNT-A is injected directly into an offending muscle and, depending on the
size of the muscle being injected; dosing has ranged between 10 and 200
units (U). Current practice is to wait at least 12 weeks before reinjection
and not to administer a total of more than 400 U in a single treatment session.
Because this upper limit of 400 U may be reached rather quickly, a different
strategy is needed for the limb requiring many proximal and distal injections.
BoNT-A and phenol may be combined, with BoNT-A being injected into smaller
distal muscles and phenol aimed at larger proximal ones. BoNT-A injections
have gained much popularity in the past several years. The advantages of
BoNT-A are its ease of injection and the lack of residual scarring after injection.
The disadvantages of BoNT-A toxin are its high cost and antibody formation,
which requires higher doses for repeated injections. Phenol, by contrast, requires
more technical expertise to localize the nerve or motor points for injection.
Phenol is caustic and causes localized scarring of the nerve and muscle. On
the other hand, phenol is inexpensive and readily available.
Casting
A combination of peripheral nerve blocks and casting or splinting techniques
are commonly used to give temporary relief of spasticity. Casting maintains
muscle fibres length and diminishes muscle tone by decreasing sensory input.
Local anesthetic nerve blocks are very helpful when they are administered
before cast application because relieving the spasticity allows for easier limb
positioning. Casts are used primarily for the correction of contractual deformities
by applying a cast on a weekly basis. Serial casting is most successful when
a contracture has been present for less than 6 months.
MANAGEMENT OF RESIDUAL DEFORMITIES

Neurological recovery reaches plateau within 6 months. Decisions can then
be made regarding surgery to correct limb deformities and rebalance the muscle
forces. This is the phase during which orthopedic surgery can made greatest
contribution.
Rationale of Orthopedic Surgery

The orthopedic surgical techniques used to correct limb deformities from
inappropriate muscle activity are release, denervation, lengthening, or transfer.
Muscle or tendon release removes the deforming force of that muscle. Release
is only used on muscles with no potential for function. A release corrects
both active deformity and a static contracture. Denervation of a muscle removes
the deforming force of that muscle and is useful when no fixed contracture
is present.
Lengthening of a muscle-tendon unit diminishes the spastic response to
quick stretch (spasticity) in a muscle that has volitional use. By removing
the overactive stretch response of the muscle, its volitional use is significantly
improved. Lengthening of a muscle tendon corrects both static and dynamic
deformities. Lengthening is often performed exclusively to correct a dynamic
deformity. When the patient is under general anesthesia and the muscles are
relaxed, a purely dynamic deformity (e.g. an equinus foot deformity) appears
corrected. Even then muscle is lengthened to decrease its activity during function.
This is one situation where muscle is lengthened to decrease its activity even
in the absence of a fixed contracture.
Transfer of a muscle-tendon unit redirects a muscle force. It is not necessary
for the muscle to have normal control. It is critical that the transferred muscle
has a predictable action to achieve the desired result.
Timing and Realistic Expectations of Orthopedic Surgery

When evaluating patients with CNS dysfunction, questions commonly arise
regarding the indications for surgery, the cost, what outcome to expect, and
the practicality of this approach. These issues should be considered on an
individual basis for each patient. The following general principles can serve
as guidelines for decision-making.
 Operate early, before deformities are severe and fixed. Orthopedic surgery
is a powerful rehabilitation tool. It is often the only treatment that will
correct a limb deformity or improve function. Surgery should not be considered
a treatment of last resort when conservative measures have failed. Physical
and occupational therapy cannot effect a permanent change in motor control.

Drug therapy for increased muscle tone has generalized effects and cannot
be targeted to specific offending muscles. Phenol blocks and botulinum
toxin injections provide only temporary modulation of muscle tone. When
a permanent treatment is needed to decrease muscle tone or redirect muscle
force, consider surgery. The results of surgical intervention are improved
when deformities are corrected early. Less muscle lengthening is needed
when deformities are mild and there is little or no fixed contracture to
overcome. Early surgery preserves maximum muscle strength, joint capsule
and ligament flexibility, and articular cartilage integrity. In general, the patient
will also be in better physiologic condition to undergo surgery if there
has not been a period of several years of immobility.
 Better underlying motor control means better function for the extremity.
Orthopedic surgery cannot impart control to a muscle. Lengthening a spastic
muscle can improve its function by diminishing the overactive stretch response
and uncovering any control that is present. Successful surgery depends on
a careful evaluation preoperatively to determine the amount of volitional control
present in each individual muscle that is affecting limb posture and movement.
Surgery should not be reserved only for patients with severe impairment
and deformity. Individuals with milder degrees of impairment can benefit
greatly from relatively simple procedures such as lengthening of the Achilles
tendon to regain a plantigrade foot for standing, transfers and ambulation.
The amount of improvement correlates best with the degree of underlying
motor control and not the severity of the deformity.
 Consider the cost of not correcting limb deformities. The cost of performing
a surgical procedure is likewise limited when compared with a lifetime
of attendant care, spasticity medications, repeated blocks, orthotics to control
limb position, complications such as skin ulceration, infection, fractures
due to fall and lost productivity for the patient and caretakers.
 No soft tissues surgery will be successful if there is an underlying bony
restriction. Preoperative radiographs are essential to assess joint congruency,
or to detect heterotopic bone or other deformity.
COMMONLY SEEN RESIDUAL DEFORMITIES AND

THEIR MANAGEMENT
Shoulder
The paretic shoulder deserves special attention because it is a common source
of pain. A variety of different factors contribute to the painful, immobile shoulder:
spasticity with adductors, internal rotation contracture, inferior subluxation

and adhesive capsulitis.
Adducted and Internally Rotated Shoulder

The arm is adducted tightly against the lateral chest wall, and shoulder internal
rotation causes the forearm to lie against the middle of the chest. The tendon
of pectoralis major is often prominent when the examiner attempts to abduct
and externally rotate the shoulder but other muscles contribute to the deformity.
The glenohumeral joint normally functions as a universal joint, enabling the
hand to reach an almost spherical volume of locations in three-dimensional
space. When patients attempt to reach forward, spastic adductors and internal
rotators can severely restrict acquisition of targets in the environment and
on the body. The patient’s ability to stabilize, push, or apply force to an object
is also compromised. From the perspective of passive function goals such
as skin care and axillary hygiene, spastic adductors and internal rotators hinder
efforts of caregivers to gain access to the axilla to provide needed care. Restricted
motion may impair dressing, washing and bathing, and promote skin irritation
and maceration. Passive manipulation of the shoulder during personal care
may cause pain and trigger spastic resistance in reactive muscles.
Muscles that contribute to spastic adduction and internal rotation dysfunction
of the shoulder include latissimus dorsi, teres major, the clavicular and sternal
heads of pectoralis major and subscapularis. Involvement of latissimus dorsi
and teres major should be considered when hyperextension posturing of the
shoulder is observed. Antagonistic activity in these muscles may be masking
a patient’s potential for active flexion. Diagnostic lidocaine block to the
thoracodorsal nerve or the lower subscapular nerve may unmask that voluntary
potential. When the pectoralis major is chronically spastic, the musculotendinous
insertion of pectoralis major is prominent and tight. However, the two heads
of this muscle may be differentially spastic, and EMG recordings from each
or diagnostic lidocaine blocks to medial and lateral pectoral nerves may help
to distinguish whether one or both heads are pathophysiologically active. Release
of all four muscles may be required to relieve the deformity in a nonfunctional
extremity. In patients who have evidence of underlying control of muscle
function, despite the presence of dyssynergy, the pectoralis major, latissimus
dorsi and teres major muscles can be fractionally lengthened at their muscle
tendon junctions. Alternately, the teres major muscle can be partially released
from its origin on the scapula and allowed to slide distally in the same manner
as the supraspinatus slide.
Inferior Subluxation
Inferior subluxation of the shoulder is a common occurrence in patients with
flaccid paralysis of the shoulder girdle. The subluxation is usually self-limiting,
but occasionally, the shoulder will be chronically subluxated, causing pain.
The patients typically have no functional use of the extremity. Patients complain
of increased pain when upright. The pain may be due to chronic stretch on
the shoulder capsule or from traction on the brachial plexus. Physical examination
shows a positive sulcus sign, with little to no active motion of the involved
shoulder. There is a prominence of the acromion and atrophy of the deltoid.
There may be contracture of the shoulder in adduction and internal rotation.
Radiographs show inferior subluxation of the humerus on the glenoid.
Conservative treatment may include electrical stimulation to the deltoid
and supraspinatus muscles use of a sling. This relieves the symptoms by elevating
the humeral head in the glenoid. Although, this technique is usually successful
in the short run, this is frequently unacceptable to the patient as a permanent
solution. A surgical solution to this problem of excessive laxity is the biceps
suspension procedure. This procedure converts the long head of the biceps
tendon to a proximally based suspensory ligament. This preserves passive
shoulder motion while correcting the subluxation.
Spastic Abduction
Overactivity of the supraspinatus muscle can cause spastic abduction posturing.
The deformity is usually dynamic, becoming more prominent with ambulation,
transfers, or other attempted activities. The affected arm is held in an abducted
posture, making balance while ambulating difficult. Patients complain that
their balance is thrown off because of bumping into furniture, doorways, and
people in crowds. Diagnosis requires examination of the patient at rest and
during a variety of activities. It is also helpful to elicit from caretakers or
family members any history of activities that trigger this posture.
Adhesive Capsulitis
Adhesive capsulitis is commonly seen in patients following stroke. They have
a characteristically painful shoulder with limited glenohumeral motion. Three
clinical and four arthroscopic stages have been identified. The treatment in
this group of patients is similar to that for the general population. Nonsteroidal
anti-inflammatory drugs, physical therapy, and intra-articular injections are
all useful.
Elbow
Spastic Flexion
Upright posture favors hypertonia in the antigravity elbow flexors of the upper
limb. In the patient without motor control, severe flexion posturing can lead
to skin maceration in the antecubital fossa, malodor, and skin breakdown.
In reality, a continuum of volitional control is seen. Many patients complain
that their elbows persistently ride up when they stand up and walk. They
also complain that their flexed elbow hooks door frames and other people,
and that putting on a shirt or jacket is a struggle. Elbow flexion shortens
the upper extremity. Consequently, reaching for objects is affected.
Functional Elbow Lengthening

Control of limb placement depends on both shoulder and elbow control. Smooth
control of elbow flexion and extension is frequently impaired. The usual clinical
picture is one of cogwheel motion on attempted extension of the elbow. Elbow
extension range is often limited with a very prolonged period of extension.
Elbow flexion is relatively normal. Dynamic EMG combined with electrogonio-
metric measurement of elbow motion of stroke patients has revealed a consistent
pattern of muscle activity responsible for this clinical picture. The pattern
most commonly seen is that all three heads of the triceps muscle are operating
in a normal phasic pattern. The brachioradialis muscle most frequently shows
continuous spastic activity. One or both heads of the biceps muscle are also
spastic. Less spasticity is observed in the brachialis muscle. Armed with this
information, a rational surgical plan can be devised to improve elbow control.
Fractional (myotendinous) lengthening is preferred whenever possible in
spastic muscles. This allows the underlying tone and strength of the muscle
to determine the amount of lengthening rather than having the surgeon estimate
this elusive quantity. Lengthening over the muscle belly eliminates the need
for suturing, and this diminishes the amount of scarring that occurs. A new
tendon reforms and fills in the gap within several months. The fractional
lengthening technique allows the patient to begin gentle active motion
immediately after surgery because the muscle tendon unit remains intact. In
contrast, a Z-lengthening technique requires immobilization for a minimum
of 4 weeks to allow healing of the relatively avascular tendon and prevent
inadvertent rupture.
Three methods are available to decrease tone in a spastic brachioradialis.
Surgical lengthening of the brachioradialis can be used, if volitional control
is demonstrated on EMG. If little or no control is demonstrated, release of

the severely spastic brachioradialis muscle at the level of the elbow may be
performed. Lengthening of the spastic biceps and brachialis muscles also
improves elbow motion and hand placement.
Nonfunctional Elbow Release

Persistent spasticity of the elbow flexors causes a myostatic contracture and
flexion deformity of the elbow. This results in skin maceration and breakdown
of the antecubital space. This position of severe elbow flexion also predisposes
the ulnar nerve to an acquired compression neuropathy by increasing the
vulnerability to direct pressure and decreasing the cross sectional area of the
cubital tunnel. In such case, surgical release of the biceps tendon and
brachioradialis muscle combined with lengthening or release of the brachialis
are performed. Gradual extension of the elbow with serial casting or physical
therapy corrects the preoperative deformity and decreases the ulnar nerve
compression. Anterior transposition of the ulnar nerve may be necessary to
improve ulnar nerve function further.
Spastic Extension
Spastic extension of the elbow is much less common than spastic flexion.
They complain of difficulty reaching their face for activities of daily living.
When needed, surgical lengthening in the form of V-Y triceps plasty allows
improved flexion range of motion, at the cost of decreased extension power
and extensor lag. Use this procedure with caution in patients who rely on
their arms to assist with ambulation or transfers because triceps strength is
lost with lengthening procedure.
Forearm
Supination and pronation deformities are commonly associated with elbow
spasticity, wrist spasticity, or both. Pronation deformities are much more common.
These deformities are most often treated together with the associated deformities.
They seldom require treatment individually.
Spastic Pronation
Pronation bias makes it difficult for a person to reach for a target underhand,
whereas supination deformity impairs reaching for targets that require overhand
reach. Many activities of daily living depend on active supination. The use
of feeding and grooming utensils and clothes fasteners becomes problematic

when spastic or contracted pronators which restrict supination. Physical
examination reveals a fully pronated resting position of the forearm. When
passive supination range of motion exceeds active supination range, the
possibility of pronator muscle dyssynergy during active supination should be
suspected. Muscles that contribute to this are pronator teres and pronator
quadratus. During the period of functional recovery, phenol or botulinum toxin
may be injected into either or both pronators. In the period of residual deficits,
surgical lengthening of pronator teres and pronator quadratus may be performed
depending on their individual voluntary capacities and the clinical goal is
to improve active supination function by reducing pronator dyssynergy.
Spastic Supination
Spastic supination is a far less common deformity but is also associated with
elbow flexion deformities. The biceps, supinator, or both may cause supination
deformity. In the functional extremity, perform a biceps Z-lengthening. In a
nonfunctional extremity, perform a distal biceps release. Often, at the conclusion
of this procedure, the arm is able to achieve a functional range of pronation.
If not, attention must be turned to the supinator.
Wrist
A flexed wrist is common after stroke but hyperextension deformity may also
be seen. Patients complain of difficulty inserting their hand into shirts, jackets,
and other narrow openings and they frequently have pain on passive motion.
They may also have symptoms of carpal tunnel syndrome secondary to
compression of the median nerve against the transverse carpal ligament by
taut flexor tendons.
Spastic Flexion
Muscles that potentially contribute to wrist flexion include the flexor carpi
radialis (FCR), flexor carpi ulnaris (FCU), palmaris longus (PL), flexor digitorum
sublimis (FDS), and flexor digitorum profundus (FDP). Singly or in combination,
these muscles may have variable features of spasticity, contracture, and voluntary
control. Because they have a larger cross-sectional area, wrist flexor muscles
are generally stronger than their extensor counterparts. Despite a net balance
of forces favoring flexion, the extent to which a patient may have voluntary
control over wrist extensors should be investigated by temporary diagnostic
motor point blocks.
Begin clinical examination by observing resting posture of the wrist. FCR,

FCU, or both may bowstring across the wrist, and radial or ulnar deviation
suggests their respective involvement. A clenched fist points to extrinsic finger
flexors as having a role. If finger nails dig into the palm, FDP is likely to
be involved. If the proximal interphalangeal (PIP) joint is markedly flexed
but the distal interphalangeal (DIP) joint is not, involvement of FDS is likely.
In an extremity with good volitional control, perform fractional lengthening
of the appropriate wrist and extrinsic finger flexors.
When wrist flexion deformities are severe and there is little or no function
seen in the hand, perform a release of the wrist flexors. Then stabilize the
wrist with a wrist fusion to eliminate the need for a wrist orthosis after surgery.
Gravity alone can cause a recurrence of the flexion deformity. Because the
median nerve is compressed against the proximal transverse carpal ligament,
causing a painful neuropathy, perform a carpal tunnel release as well.
Hand
Functional Procedures versus Procedures for Hygiene
Preoperative evaluation is performed to determine which extremities have
sufficient volitional control of the muscles to allow surgical procedures aimed
at restoring function to the hand. Often, severe deformities are present, but
there is insufficient or no volitional activity in the muscles. In these cases,
perform contracture releases to decrease pain, improve position and cosmesis
of the hand, and to ease basic skin care and hygiene.
During the period of residual deficits, a variety of orthopedic options are
available. When volitional control is demonstrated in the extrinsic flexor muscles,
the fractional lengthening is indicated. In a hand with skin maceration and
malodor from a clenched fist deformity in which no volitional movement is
detected, more significant lengthening of the flexor tendons is required. In
this situation, perform a superficialis-to-profundus (STP) tendon transfer.
Spastic Thumb-in-palm Deformity

The thumb-in-palm deformity may result from spastic activity in FPL, adductor
pollicis (AP), or the thenar muscles, particularly flexor pollicis brevis. The
thumb is held within the palm, the DIP joint of the thumb is commonly flexed,
and the thumb is unable to function during key grasp. In addition, skin maceration
and breakdown can occur if proper hygiene is prevented. Clinically, spasticity
of the flexor pollicis longus is indicated by flexion of the interphalangeal
joint. Some patients may be able to extend the thumb if the wrist is flexed.
Adduction of the thumb metacarpal indicates spasticity of the AP muscle and
possibly the first dorsal interosseous muscle. A quick stretch of the thumb
into abduction often elicits a clonic response. An anesthetic block of the ulnar
nerve in Guyon’s canal at the wrist temporarily eliminates intrinsic tone. This
will demonstrate the presence of any myostatic contracture and will also confirm
that the AP was an offending muscle in the deformity. Contracture of the
skin of the web space and interphalangeal joint contracture of the thumb may
also develop over time. If some volitional potential in thumb extensors or
thumb abductors is present, lengthening of the spastic FPL and AP will facilitate
key grasp. In the period of residual deficits and remediable function, orthopedic
treatment consists of fractional lengthening of the FPL at the myotendinous
junction combined with a thenar muscle slide, in which the origins of the
thenar muscles are detached from the transverse palmar ligament while preserving
the neurovascular pedicle. Fractional lengthening of the FPL at the myotendinous
junction will improve thumb extension. This is generally performed in
conjunction with wrist or digital flexor lengthening. In order to provide a
functional lateral pinch, it is desirable to stabilize the interphalangeal joint
of the thumb. In those cases with a fixed adduction contracture, perform surgical
lengthening of the thenar muscles.
Deformities from Intrinsic Spasticity

When spasticity of the extrinsic flexors is present, intrinsic spasticity should
be expected. However, intrinsic spasticity and contracture are frequently masked
by the presence of extrinsic flexor spasticity or contracture. Extension of the
fingers at the metacarpophalangeal joints may be blocked by spasticity of
the interossei and lumbrical muscles of the hand. Another manifestation of
intrinsic spasticity is the tendency to swan-neck or boutonniere positioning
of the fingers. These hand deformities can be painful and disfiguring. Such
contractures often lead to maceration of the palmar skin and recurrent nail
bed infections from poor hygiene.
The degree of tension caused by the intrinsic muscles can be demonstrated
by comparing the amount of proximal interphalangeal joint flexion obtained
with the metacarpophalangeal joints, both flexed and extended. If there is
less proximal interphalangeal joint flexion with metacarpophalangeal joint
extension, then the intrinsic tendons are tight. Perform this test, both before
and after a lidocaine block of the ulnar nerve at the wrist, in order to distinguish
between intrinsic tone and contracture.
Boutonniere deformities are commonly associated with intrinsic spasticity.

They result from a combination of intrinsic spasticity combined with FDS
tone. Swan-neck deformities may also result from increased intrinsic tone.
The central extensor band is relatively shortened relative to the lateral bands
because of tension exerted by the intrinsics and long extensor.
In the period of residual deficits, three treatment options are available. The
procedure chosen is based on considerations of contracture and the presence
or absence of volitional activity in the intrinsic muscles. When no significant
intrinsic contracture is present and there is no volitional control in the intrinsic
muscles, perform a neurectomy of the motor branches of the ulnar nerve in
the palm When a contracture of the intrinsic muscles is present and no volitional
activity, perform a release of the lateral bands of the extensor hood mechanism
at the level of the proximal phalanx. In these cases, neurectomy of the motor
branches of the ulnar nerve is performed simultaneously to prevent recurrence
of the intrinsic plus deformity from spasticity of the interosseous muscles.
When there is either a dynamic or static intrinsic plus deformity and volitional
control, release the interossei from their proximal origins on the metacarpals
and allow to slide distally. A static deformity is one in which a myostatic
contracture is present. A dynamic deformity is one in which the deformity
results mostly from increased tone with little or no fixed contracture.
Hip
Adduction Deformity
Scissoring of the legs in an ambulatory patient gives the patient a narrow
base of support while standing and results in poor balance. A preoperative
obturator nerve block eliminates the adductor spasticity and allows assessment
of the adduction contracture. Alternatively, the patient can be examined at
the time of surgery while under anesthesia, to determine if a fixed myostatic
contracture is present. When no fixed adduction contracture is present, transection
of the anterior branches of the obturator nerve will denervate the adductors
and allow the patient a broader base of support. Commonly, a small contracture
is found and the adductor longus muscle is released at the time of the obturator
neurectomy.
A hip adduction contracture that interferes with nursing care and hygiene
in a nonambulatory patient or excessive limb scissoring during attempted transfers
and ambulation in a patient with active function are indications for surgical
release. In a severely spastic patient, a flexion contracture of the hip and
knee commonly occurs in conjunction with an adduction contracture.
Flexion Deformity
Spasticity of the hip flexors can result in a crouched gait with compensatory
knee flexion to maintain balance. This is a very costly deformity because
it requires constant use of the quadriceps, hip extensor, and calf muscles to
maintain upright posture. The energy requirement for the continuous firing
of these muscles is extremely high. Few patients are able to remain ambulatory
with this deformity.
The hip flexor muscles are needed to advance the limb during gait. Avoid
complete release of the hip flexors in any patient with the potential to ambulate.
Nonfunctional Release Complete Hip Release

for Severe Contracture
A hip flexion contracture or severe spasticity in a nonambulatory patient that
causes poor hygiene or pressure sores that cannot be healed secondary to
limited positioning of the patient are indications for surgical release. An adduction
contracture of the hip and a flexion deformity of the knee are commonly
associated with a hip flexion contracture in the severely spastic patient. When
a severe adduction contracture of the hip is present, it may be necessary to
perform a percutaneous release of the adductor longus tendon in the groin
in order to position the patient adequately and prepare for further surgery.
Simultaneously, correct any flexion contracture of the knee to prevent the
leg from positioning in flexion and causing a recurrent and more resistant
contracture.
Knee
Flexion Deformity
A knee flexion deformity is caused by overactivity of the hamstring muscles.
When the knee flexion deformity is less than 60° and the patient has documented
volitional activity in the hamstring muscles, perform a lengthening procedure.
This approach will correct the flexion deformity while preserving the function
of the hamstrings.
In a nonambulatory patient with severe spasticity of the hamstring muscles
or a knee flexion contracture of greater than 60° is present, attempts to correct
the knee position with casting or bracing may result in posterior subluxation
of the tibia. Distal release of the hamstring tendons does not prevent a patient
from becoming ambulatory. If the hip flexion contracture or spasticity is not
corrected at the same time as the hamstring release, a recurrent knee flexion
contracture is likely to develop that is very resistant to surgical correction.
Dynamic Stiff-knee Gait

Patients with a stiff-knee gait are unable to flex the knee during the swing
phase of gait. The deformity is a dynamic one, meaning that it only occurs
during walking.
There is no restriction of passive knee motion, and the patient does not
have difficulty sitting. Usually, the knee is maintained in extension throughout
the gait cycle. Toe drag, which is likely in the early swing phase, may cause
the patient to trip; thus balance and stability are also affected. The limb appears
to be longer functionally. Circumduction of the involved limb, hiking of the
pelvis, or contralateral limb vaulting may occur as compensatory maneuvers.
Abnormal activity is also common in the rectus or vastus intermedius muscle.
If knee flexion is improved with a block of the rectus femoris or vastus
intermedius muscle, the rationale for surgical intervention is strengthened. Any
equinus deformity of the foot should be corrected before evaluation of a stiff-
knee gait because equinus causes a knee extension force during stance.
Transfer of the rectus femoris to a hamstring tendon not only removes
it as a deforming muscle force, it also converts the rectus into a corrective
(flexion) force to facilitate knee flexion during swing.
Ankle
Equinus Deformity
Equinus is the most common spastic deformity that causes gait difficulty. Equinus
results from the overactivity or premature activity of the gastrocnemius and
soleus muscles. Surgical lengthening of the Achilles tendon is indicated when
the patient’s foot and ankle position is not adequately controlled by an orthosis
or when attempting to make the patient brace free.
Varus
Varus deformities most commonly occur as the result of increased and
inappropriate activity of the tibialis anterior muscle. This deformity can
be corrected by a split anterior tibial tendon transfer (SPLATT). The SPLATT
maintains the half of the tendon on the medial aspect of the foot and
transfers the other half of the tibialis anterior tendon to the lateral side
of the foot.
In approximately 10% of stroke patients, the tibialis posterior muscle is
also spastic and can contribute to the varus deformity. Myotendinous lengthening,
proximal to the medial malleolus, can correct this problem.
With the equinovarus deformity, the patient may also have a hitchhiker’s
great toe secondary to spasticity of the EHL tendon. The EHL also contributes
to the varus deformity of the forefoot. Many patients with this condition complain
of shoe wear problems from pressure of the hallux against the shoe. Most
commonly, the EHL is lengthened in combination with a SPLATT procedure.
Cavus
A cavus deformity is defined as an elevated arch that does not flatten with
weight-bearing. The deformity is probably a result of muscle imbalance of
both the intrinsic and extrinsic muscles of the foot. If the foot is supple,
plantar fascia is incised to correct the deformity. If the foot is rigid, a bony
fusion must be performed.
Clawfoot
Toe clawing or curling is a common accompaniment of overactivity of the
gastrocnemius muscles. Toe curling is caused by overactivity of the flexor
hallucis longus and flexor digitorum muscle as well as the short toe flexor
and occasionally the intrinsic muscles of the foot. Flexor tendons release can
correct this deformity. This procedure is commonly performed in combination
with an Achilles tendon lengthening because bringing the foot into a plantigrade
position will worsen the toe curling.
Calf Weakness
Muscle paresis (weakness) is an integral part of UMN syndrome. Lengthening
the Achilles tendon to correct an equinus deformity weakens the gastrocnemius-
soleus muscle group, which was already weak as a consequence of the underlying
UMN syndrome. This calf paresis generally results in the need for an AFO
during ambulation. Thus, transfer of the FDL muscle can be done to augment
calf strength. With this transfer, more patients eventually achieve brace-free
ambulation. In prior study of treatment of a spastic equinovarus foot deformity,
30% of patients were able to walk safely without an AFO. When the strength
of the gastrocsoleus is augmented by transfer of the FDL to the os calcis,
70% of patients achieve brace-free ambulation.
Foot Deformities in the Nonambulatory Patient

Severe deformities of the feet are common in patients with spasticity. Even
in the nonambulatory patient, these deformities cause significant problems.
These complications include pressure sores, inability to wear shoes or protective

footwear, and difficulty positioning the feet on wheelchair supports for improved
sitting balance. Correct these deformities surgically to maintain a plantigrade
foot.
The most common deformity is equinovarus with claw toes. As in the more
functional patient, muscle balance must be achieved by performing the SPLATT,
an Achilles tendon lengthening, and release of the toe flexor tendons, release
of the plantar fascia to correct a cavus deformity.
AUTHOR’S PERSPECTIVE
Patients with stroke can initially be overwhelming to an orthopedic surgeon.
However, the care of these patients follows standard, well-known orthopedic
principles. Considering the specific limb problems individually and then
constructing a prioritization list is the most effective method of dealing with
patients who have multiple problems. As a starting point, it is helpful to consider
problems in functional categories and next to consider whether or how correction
of a specific limb deformity is likely to improve the function. Examples of
functional categories include dressing, eating, transfers and walking.
Walking is a commonly desired goal for patients and their caregivers. A
patient with a severe equinovarus foot deformity often is unable to walk.
If the patient has some active hip flexion to provide limb advancement and
good sitting balance, then correction of the foot deformity is likely to make
the patient ambulatory. It may also be necessary to correct a hand contracture
for the patient to use a cane or walker to achieve this goal. If the patient
lacks active hip flexion and has poor trunk balance, then correction of the
foot deformity will not allow walking. Correction of the foot may still be
useful to allow shoe wear or to improve sitting balance with the foot resting
on the leg support of a wheelchair.
By using a systematic approach and dividing problems into both functional
and anatomic categories, it is easier to sort through the numerous musculoskeletal
issues faced by persons with neurologic disorders. A major improvement in
function and quality of life is achieved for many, giving both the surgeon
and the patient a feeling of satisfaction and accomplishment.
Conclusion 417
C H A P T E R
20
Conclusion
INTRODUCTION
Physiotherapy and rehabilitation for the hemiplegic patients is a very complex
process, and especially the patients suffering from a longer period of time
demand lots of care, love, affection, proper treatment, understanding, apart
from the technical know-how from the treatment provider. It is, therefore,
of vital importance that the caregivers and those who are attached to the
rehabilitation of the particular patient look after the entire aspect of a person’s
well-being rather than to look at their own individual field. This is the crux
of any rehabilitation program be it orthopedic rehabilitation, sports rehabilitation,
neurological rehabilitation or post-surgical rehabilitation.
India is a vast country with diverse culture, different languages, and of
course, different individualistic needs of people. A lot has been said about
the people living in developed countries, but still, people of developing countries
and underdeveloped countries are somewhat neglected; more so with the patients.
In the medical care, the purpose and application of the treatment sometimes
differ with the country concerned. Therefore, not all the methods suggested
and successfully applied in one country will hold the same ground and will
deliver the similar result in another country. India is fast emerging as a global
social and economical power and hence, it is important that the needs of
people and the patients are looked upon in a different light focusing on the
individualistic and holistic approach integrating the modern scientific procedures
and ancient eastern wisdom.
Neurological rehabilitation is no different than the other fields of patient
care. But, then also, there is a vast difference in terms of the time taken
for the full recovery of the patient or the years of active life lost. This issue
is taken up by the WHO even in India. Thus, there is an acute need of prompt
and standardized neurological rehabilitation package for every patient of India
according to their individual needs.
In India, there seems to be a gross lack of awareness about the rehabilitation
team members amongst the patients and their relatives. Also, there is a generalized
lack of rehabilitation specialists even in major cities across India. Patients
are not aware that physiotherapy incorporates various advanced techniques,
especially for hemiplegia patients who immensely benefit in the speedy and
near normal recovery. Even in today’s advanced world, many of the patients
do not get services of qualified rehabilitation professionals. There seems to
be lack of proper education of the patient regarding sexual functions post
hemiplegia. The matter is more over complicated by the presence of the
psychological disturbances and fear of non-acceptance in the society. Lack
of vocational guidance above all does not help in reaching the ultimate goal
of returning back to the full and satisfied life. Spirituality and faith helps
the patients in fighting this dreadful disease and condition. Family support
is the main pillar and family is the most important rehabilitation team member
in Indian scenario. Strong cultural values and ethics combined with faith and
dedication from the part of the treatment provider will ensure best results
for the chronically suffering hemiplegia person.
The real heart of the treatment is to open up the eyes of the public at
large towards the gross negligence these patients are facing and they do have
a right to proper and best treatment combined with love, affection and care.
If the reality is dawned on the people, they would find out ways to combat
it with full force and then, a day will come when an ideal set up for a complete
rehabilitation care for the hemiplegia sufferers is done in our country India,
which is a pioneer in the field of medicine and has shown the world, the
most effective system of holistic medicine namely `ayurveda’, since thousands
of years.
A study carried out by this author on 81 hemiplegia patients in Western
India shows striking results which are given below.
PLACE WHERE INITIAL PHYSIOTHERAPY WAS

CARRIED OUT
Ideally, it is assumed that the patients who are admitted to the hospitals start
receiving the full rehabilitation treatment from the initial stages of their condition.
The study suggests that only 65% of the patients received the physiotherapy
treatment in the hospital where they were admitted. Twenty-five percent patients
Conclusion 419
started with physiotherapy after they were discharged from the hospital, where
the physiotherapist would go to them or home visits. Ten-percent patients
started this treatment directly as OPD patients.
This suggests that even in a developed Western India where basic medical
facilities are good, there are 35% of patients who are not receiving the treatment
timely. It is a well-known fact that if physiotherapy is started earlier, the
chances of recovery are far more beneficial than that of late treatment. An
awareness program for the first-time patients should be incorporated. Medical
and nursing staff should be educated towards the importance of early
rehabilitation and care should be taken that proper measures are taken.
PHYSIOTHERAPY TO BE CARRIED OUT BY

QUALIFIED PHYSIOTHERAPIST
Seventy-two percent patients received physiotherapy treatment by a qualified
practitioner. Twenty-seven percent received treatment from unqualified
practitioner and 1% did self-treatment initially after the hemiplegia. This is
the genuine situation of our country where there are unqualified persons
impersonating the doctors. That is the reason why 27% of educated patients
fall prey to substandard rehabilitation program and in turn ruin their lives.
The situation of such quacks is gruesome in the villages and towns where
there are not enough qualified medical professionals. Young medical professionals
do not wish to practice in villages and interiors due to lack of proper infrastructure
and hence, the patient is the sufferer at the end. This situation needs to be
addressed on a larger scale and the help of the government of India and the
nongovernment organizations is equally important as that of the doctors. The
patients and the people in general should be taught about the value of quality
medical treatment and they should become aware about their right to proper
treatment. The awareness of fundamental right of receiving good medical
attention and treatment can make the patients and their relatives more demanding
towards the treatment provider and thus, the problem of unqualified practitioners
can be minimized.
INVOLVEMENT OF REHABILITATION
PROFESSIONALS OTHER THAN
PHYSIOTHERAPIST
As discussed earlier, apart from the primary caretaker like the family physician,
neurophysician, neurosurgeon, and physiotherapist and nursing care, there are
other team members of the rehabilitation team who are of vital importance
in complete recovery of the patient. No team member is inferior to other
in terms of the importance of the treatment application. All the patients should
timely receive the services of all the members of the team and coordination
of all the members with each other is advisable for the benefit of the patient.
Eighty-five percent patients received only physiotherapy and no other
rehabilitation treatment (other than the primary caretakers). Only 15% patients
received services of other members which included occupational therapist in
2 cases, orthotist in 2 cases, speech therapist in 5 cases and clinical psychologist
in 1 case. This shows a sheer lack of understanding in the value of rehabilitation
amongst doctors, relatives of patients as well as physiotherapists.
AWARENESS ABOUT HELPFULNESS OF

REHABILITATION PROFESSIONALS
Sixty-four percent patients were aware that other than physiotherapists, there
are different rehabilitation professionals who could propel their recovery and
assist them in achieving full recovery. Thirty-three percent knew nothing about
the rehabilitation team. Only 1% patient knew about all the members of the
rehabilitation team.
When there is no awareness, the patients would not demand the services
of the full team and hence, would remain in a traumatic state coordinating
each aspect of recovery by themselves.
It is the duty of the treating doctor to guide and educate their patients
regarding the value of each member of the team as it is long since the importance
of the team is reported. In this study, 91.3% patients received information
regarding the importance of physiotherapy from their treating doctors. Only
8.7% patients were informed through other sources like family and friends.
SATISFACTION WITH REHABILITATION

Seventy-four percent patients were satisfied with their rehab program and 26%
were not satisfied with it; even when 33% were unaware about the total rehab
care!! The other factor which influences the satisfaction is the faith of the
patient in the treatment provider. In India, we have full faith in the doctor
and we also put the medical professionals close to God. In such a situation,
even if the unqualified or underqualified person is providing the treatment,
the patients will be satisfied and will not look for other options till too late.
It is a proven fact that all the treatment centers are not the same. The treatment
Conclusion 421
provided at different clinics will be bound to be different and hence, the

satisfaction level of the person would differ. Until and unless a standardized
approach is taken for neurorehab, the patients will receive different treatment
techniques and the resultant recovery will vary.
AWARENESS ABOUT DIFFERENT PHYSIO-

THERAPY TECHNIQUES AMONGST PATIENTS
Neurological physiotherapeutic techniques differ from the conventional
techniques of mobilization and strengthening. These treatment techniques are
known as adjunct therapy. Bobath, NDT, neuromotor relearning, hydrotherapy,
Rood’s approach, proprioceptive neuromuscular rehabilitation, constraint
therapy, etc. are different techniques which immensely benefit the hemiplegia
patient rather than using only the conventional therapy by the physiotherapist
Seventy-six and a half percent patients studied were not aware about any of
the neurophysiotherapeutic techniques of treatment. Only 22.2% were aware
about any of the two techniques. As the patients are unaware about the treatment
techniques, they cannot know whether they are receiving proper treatment
for their problems. This is demand and supply law. Only if there is a demand,
there will be the supply. If patients are aware, they will demand full therapy
program from the treatment provider and hence, complacency on the part of
the treatment provider will have to reduce and they will try to be more sensitive
towards the needs of the patient. As for an example, a patient starts taking
physiotherapy treatment at a certain place under guidance of a certain practitioner.
Now, it is possible that this practitioner may not be skillful enough to tackle
every aspect of rehabilitation. In this scenario, the patient will receive treatment
as per the level of understanding on the part of the practitioner and not as
the treatment should be. The treatment becomes subjective and not objective.
But, if the patient or the relatives of the patient are aware about the various
physiotherapeutic techniques, they can monitor the quality of the treatment
and demand the type of the treatment. It is obvious that in the society, now
a day, people have become aware regarding the medical field. More and more
numbers of people have started talking in medical terms and terms like
angioplasty, angiography, bypass, root canal treatment, joint replacement,
arthroscopy, laparotomy, antibiotics, antioxidants, CT scans, MRI, etc., are
commonly used in a day-to-day life amongst the lesser educated people also.
If terminology for the neurorehabilitation treatment techniques become famous
and be used by the general populace, the overall quality of rehabilitation is
bound to improve. This is the central idea of this study.
SEXUAL FUNCTIONS IN HEMIPLEGICS

In India, till today, the word ‘sex’ has got a taboo attached to it and people
are not comfortable talking about it in general public or they are not ready
to discuss their problems with anyone. Out of 81 hemiplegics which were
interviewed, only 28, i.e., only 35% of patients were ready to share their
experiences. Out of them, 14% of people were sexually inactive while 86%
were active. All the patients who were active, faced positional problems during
the act. While they could reach up to orgasm, they were not enjoying the
act as before due to their physical disability status and the chief reason being
the upper limb spasticity. Many of them had become sexually excited within
few days of their problem, but they engaged in the sexual act or coitus after
a few months. This time was as long as one year in some of the patients.
The reason for the same was the skepticism regarding engaging in sexual
act after the disease. Both the partners had fear and reservations whether to
do or not to do. They also did not ask their doctors or neither did they discuss
it with their friends due to embarrassment.
A few of the cooperative individuals in fact reported a decrease in spasticity
and a feeling of relaxation post-coitus. Juha et al. found out after a study
of 192 stroke patients that psychological and social implications were the
main reasons for the decrease on libido and a fear of impotency post-stroke
which impaired their sexual life. The right side brain damaged patients had
more problems in arousal, vaginal lubrication and orgasm than the left side
brain damage patients. A proper guidance to the spouse of the patient and
the patient themselves will provide a good education regarding the problems
associated with hemiplegia and their implications on the sexual life. This
understanding will in turn help to normalize the sexual life of the patient
and their spouses as it is of vital importance for the healthy social life and
complete rehabilitation of the patient. Alternative positions during the act can
be demonstrated to both the partners so that they can enjoy it without the
feeling of inadequacy. The hemiplegic person can assume a position of lying
on their back and their spouse can be on top to minimize the problems of
spastic upper limb coming in way and also, the pelvic thrust movements will
be done by the partner and hence, the intensity of the act will not be less.
Initially, during the more disability state, sexual arousal can be obtained
by manually caressing the genitals of the patient by the partner after a soft
talk. This can prepare the patient to overcome the fear and the patient will
feel that he/she is sexually accepted and loved. Gradually, as the recovery
comes, more and more active positions can be used and sexual satisfaction
can be used as a moral boosting activity for the patients which will encourage
them to become more and more normal in all aspects of life.
Conclusion 423
PSYCHOLOGICAL ASPECTS OF HEMIPLEGIA

Physiotherapists and all other clinicians who deal with the patients on a direct
basis need to understand the patient and their problems effectively. This will
ensure a healthy communication with the patient as well their relatives. Also,
the rehabilitation team member should make themselves understood and hence,
they all require a working knowledge about the psychology of a chronically
ill patient. It is a proven fact that all the hemiplegic patients suffer from
some or the other kind of psychological problem. This includes mood swings,
depression, lack of concentration, decreased initiation, distortion of self-image,
loss of confidence and totally giving up attitude for the recovery. Depression
is more common after 6 to 8 months of the initiation of hemiplegia. Nevertheless,
it is the duty of the treatment provider to diagnose the problem and help
patient cope up with it or if it is absent then, to prevent it altogether.
Out of the 81 patients which were interviewed, 68% of people complained
of mood swings at the end of six months of their problem; while, the numbers
were as high as 85% in the initial stages. Thirty-two percent of patients had
settled psychologically when the condition had become chronic. This suggests
that as the time passes, more and more numbers of patients learn to cope
up with their disability which was difficult initially. The distortion of the self-
image was the biggest factor for such a kind of condition. The thought that
when they would get full recovery bogged all the patients. The patients who
had more frequent mood swings were the ones who had a negative thought
process that they would never recover. The study shows that the actual motor
recovery of the patient was no meter for the negative thought process. Seemingly
recovered patients i.e., 90 to 100 on Barthel index also showed increased
mood swings and negative thoughts.
It was a pleasant surprise to know that 88.88% patients had accepted their
condition. The remaining 11% of the unfortunate ones had not still accepted
the condition of their disability. The acceptance doesn’t mean that the patients
accepted the disability and did not want to do anything for that. In fact, they
were the patients who were really motivated for trying out all the measures
which will make them as normal as possible. The persons who did not accept
the condition blamed many factors for their condition and hence, their
concentration and zeal for carrying out physiotherapy was not as good. This,
in turn, reduced the output of their therapy and they lagged behind in every
aspect of their rehabilitation.
Twenty-four percent patients had a vague feeling of totally giving up every
measure for their recovery due to frustration and longer time of the recovery.
This type of feeling was not a constant one on many of them, but, was a
passing feeling sometimes. It was commonly seen that the immediate relatives
of the patient complained that the patient has become increasingly irritable
and short-tempered. Though all of them take it lightly, this feeling should
be curbed with proper counseling of the patient and the caretakers before
it takes a definite form of some psychological condition. The irony is that,
most of the patients denied of becoming irritable, clearly showing that they
themselves were not happy about this feeling and were not, therefore, accepting
it.
As the acceptance of the condition increases gradually, the frequency and
intensity of mood swing decreases. The understanding of the pathogenesis
of the disease and the education regarding the proper rehabilitation techniques
reduces the anxiety levels of the patient and their relatives.
SOCIAL FUNCTIONS
Social functions and psychological functions are very closely associated with
each other. Man is a social animal and a family being. No one loves to live
an isolated life. Due to the physical disability, the person’s efficiency of routine
activities decreases and hence, there are a lot of chances that that person
starts feeling isolated and dejected. He is unable to move out for the recreational
activities as before and that multiplies the problem of social isolation. The
closely knitted family system of our country gives a fillip to faster accommodation
of the situation. Other way round the same system can prove to be very
demanding on the patient if the family members are more expectant. But,
overall, the family support system is a good tool and a very important part
of complete rehabilitation.
Many patients have a feeling of fear of non-acceptance in the society due
to the disability status. They feel inferior to the so called normal individuals
and hence they feel low in their presence and hence, avoid going to places
where they are not feeling absolutely comfortable. Out of 81 patients, 53%
patients had a fear of non-acceptance. This feeling can be tackled by a sensitive
approach towards the patient and proper counseling. The patients should be
encouraged to move out of the house as early as possible, due to which,
they would come in contact with the world, early in the rehabilitation process.
The real life situations would put demands on them, and by successfully tackling
them, they would feel confident and the fear would minimize. General public
should be taught to be more sensitive towards the disabled or differently-
abled persons and their behavior should be of helping and not ridiculing.
It is commonly seen that if these patients are given too much of attention
Conclusion 425
and if people feel too sorry for them, they do not like it and hence, such
a type of behavior should be totally avoided. They should not be talked to
as if talking to a child. This is a common mistake people make. One should
remember that the patient is an adult and is differently-abled; not a child
or a mentally challenged person.
The fear of non-acceptance may not always mean that the patients do not
mingle with others easily. The study suggests that only a 26% of people have
difficulty in mingling with others. The main reason is the feeling of inferiority
and a fear of non-acceptance. The interaction of the environment and the
response of the patient towards them influence this factor. Almost all the patients
reported a significant increase in spasticity when they went to a newer place.
The gait or the walking pattern also changed significantly. The apprehension
and anxiety towards newer places increases manifold even in chronic cases.
A positive attitude and self-suggestion or autosuggestions may minimize the
problem to a greater extent.
All the patients had an excellent family support; which is evident from
the study. Ninty-five percent patients reported of having a very good family
support. This is very important because, when the patient is having disability
and is dependent, there is an acute need of love and care which is provided
best by the immediate family members and the friends. The affection which
the family provides is not obtained by paid staffs which are available in India.
The family support is indispensable and cannot be replaced by even rehab
experts in the country like India. The family is one of the three pillars on
which the entire recovery depends. The other two pillars are the rehab experts
and the patient himself.
Seventy-three percent patients went for the recreational outing as before.
This included the visits to relatives, restaurants, movie halls, shopping and
others. This is a good index as a person will feel fit only if he can move
out of the house for recreation and merry making. This kind of routine will
ease out undue stress in the mind of the patient and he will become free
and light. This will ensure an increased zeal in carrying out the required task
for the recovery. The remaining 27% patients could not go out for recreation,
mainly due to the physical status and the feeling that they were dependent
and will have to take assistance from somebody for their recreation. In western
developed countries, there are qualified recreational therapists who are associated
with the rehabilitation team and who provide timely recreation to the patient
right from their hospital stay. The rehabilitation hospitals are equipped with
the gaming zones, gardens and libraries so that patients of all age groups
get recreation of their choice. Physical activity of choice will facilitate the
brain and in turn facilitate motor response to the limbs; thus increasing the
chances of faster recovery. In our country, such kinds of recreational therapists
are not possible to have due to budget constraints and lack of proper
infrastructure. But, nevertheless, this work is done by patient’s family and
friends and rehabilitation specialists like the physiotherapists as they are the
ones who spend more time with the patient than any other specialist.
It is usually seen that the sporting activity and life-like situation activities
generate and facilitate quality motor movements from the brain. This fact
can be utilized to a beneficial aspect in all the hemiplegic patients in all
the stages. Even if they do not possess any motor recovery, they can indulge
in such playing activity using their normal side. This will facilitate the activity
from the brain. Playing cards, ball, simple games, should be started early.
More advanced games and sports like ball catching and throwing, hitting the
ball with clasped hands, hitting the ball with the affected hand, etc. can be
extremely helpful. As the recovery progresses, ball catching and throwing can
be progressed on the wobble or the balancing board. Playing indoor cricket,
badminton, volleyball, basketball can be incorporated as soon as possible.
This will ensure an increase in the motor function as well as provide recreation
to the patient.
In our environment, government hospitals and some private hospitals do
have a rehabilitation unit, where recreation facilities are available. But due
to difficulty in handling and lack of proper attention, these units are existent
merely on paper only and the actual work on the patients is still not up to
the mark. Well, there are some exceptions but owing to the size of our country
India and sheer numbers of our patients, these units are extremely less. The
private physiotherapy clinics where most of the patients go for treatment do
not have enough space and enough time to take care about this and hence,
the patients are the sufferers in longer run.
SPIRITUALITY AND FAITH

All the patients, despite their faith and religion, told to have faith in the almighty.
It was seen that 16% of the patients had increased faith in the god. The
reason for the same was the fact that they had accepted their condition and
saw the presence and will of the Lord in their condition. Seventy-nine percent
of the patients did not find any change in their faith, and were as religious
as before. Only 5% patients reported of having decreased faith. These patients
had a grudge that why they were given this problem by the lord. They found
it very difficult to accept their condition. Also, they had a higher chance
of feeling of depression than others. It is a known fact that faith can heal
Conclusion 427
and modify most of the problems. The religious faith can increase the acceptance
of the condition and can prepare the patient to be patient and face the challenges
which are posed by the disability. Faith induces an increase in inner strength
of the person. It is a known fact that the positive thinking and autosuggestions
along with the religious practices help in speedy recovery of the patient. Chanting
of the Lord’s name along with meditation can decrease spasticity by providing
deep relaxation and increase in alpha rhythm activity in the brain.
WORK AND PROFESSION

According to the study, out of 81 examined chronic hemiplegia sufferers, 30%
patients had never gone for any work. Either they were females as home
makers or were students. Out of the remaining 57 patients, 61% patients had
resumed their previous job or business, while 39% could not resume their
duties again. Out of the home makers and students, all the students and 50%
home makers had resumed their previous work.
The study clearly suggests that approximately 40% patients were unable
to resume their work due to their physical disability status. Most of them
had lack of confidence and inability to cope up with the work place. In India,
most of the public places including the offices and the recreational areas are
not accessible easily for the disabled or differently-abled individuals. The public
transport system is not disabled person-friendly even in a developed cities.
The towns and villages lack basic public transport altogether. Thus, for the
patient, going to the workplace is difficult, if he/she is unable to drive their
own vehicle. Otherwise, they have to utilize autorickshaw or taxi which is
not economical for daily use and hence, such patients cannot resume their
work.
When a person becomes disabled like in this case, hemiplegia, they are
off from the work for a long period of time. When they resume walking
and going out, they may not be using their affected upper limb effectively
and the patients who have proprioception and perception problems do not
feel confident in carrying out their duty. Due to this problem, they think that
their work efficiency would be less, and sometimes even the employer
discourages them from resuming duties. To add to the problem, we do not
have a vocational guide as our rehabilitation team member. The vocational
guide assesses the potential and disability of the patient and accordingly advices
the patient for the type of the work they can attempt successfully. The young
hemiplegia victims have entire professional life ahead of them and sometimes
these patients are still in school or colleges and so, they need proper guidance
regarding their future profession. Due to lack of this training, they feel frustrated
and depressed and their problems increase rather than decrease as the time
passes. Thus, a timely counseling with the vocational guide can ease out the
worries of the patient and they can return to the work of premorbid state
or can take up a new profession and earn and support themselves and their
family.
In India, the patient spends most of the time with the physiotherapists.
In cities and in midsize towns, physiotherapists are readily available. Apart
from the big centers, most of the times, they are the only rehabilitation team
members associated with the patient. Physiotherapist, therefore, should be
equipped to deal with such a situation. Patients should not be deprived of
the total rehab care and hence, physiotherapist should at least provide information
regarding the importance of the other team members and should provide basic
treatment.
Thus, it is not really surprising that some of the resourceful physiotherapists
also provide vocational guidance to the patient and help the patient for complete
rehabilitation. Active involvement of the rehabilitation team member and working
in interdisciplinary manner becomes advisable in a country like India. Relatives
of the patient are one of the most important team members and hence, their
assistance should always be taken. Their assistance is readily available and
is economically cheap. They can spend a lot of time with the patient and
their services are invaluable.
It is a wish and dream of every chronic hemiplegia patient to have full
recovery and lead a normal and a fulfilling life as soon as possible.
FUNCTIONAL RECOVERY
It is important that both the patient and the treating physiotherapist have a
harmonious relationship regarding the treatment and its effect leading to recovery.
Goals of both the parties should be the same. The road to recovery is long
and tedious and always demands lot of mental strength and patience. The
treatment of hemiplegia is a continuous process and should not be dependent
upon discrete therapy sessions. The final outcome of recovery is dependent
upon many factors. The site and extent of lesion in the brain is the most
important of the factors. Then, the amount and quality of treatment including
the physiotherapy and rehabilitation and participation of patient are other very
important factors. Patients always want very speedy recovery. They may not
be totally aware regarding the site and extent of the brain damage and so,
they may not even estimate the time of recovery correctly. They should be
told about the method of recovery and they should be educated that the recovery
Conclusion 429
is a process and not a destination in this case. When the treatment provider
and the patient are working harmoniously, their goal is same and the attitude
is focused. When the harmony is distorted due to various reasons, even when
the recovery of the patient is good enough for the brain injury they possess,
they may not feel the same. Sometimes, only the maintenance of the condition
and prevention of further deterioration may be the goal of the therapist. But,
if the communication between the patient and the therapist is improper, patient
may feel less or no recovery.
AN IDEAL REHABILITATION OF A PERSON

SUFFERING FROM HEMIPLEGIA
A Vision and a Mission
In India, the rehabilitation of the hemiplegic patient can be bettered by using
the resources already existent and incorporating more proactive approach towards
the patient care. The ideal rehabilitation model is as follows.
 The patient is immediately admitted to the hospital on the first signs of
motor weakness in any of the limbs or the face or any difficulty in speaking.
In the case of an accident where there is any evidence of the head injury,
the neurological examination is performed and signs for the brain damage
are looked out for.
 Emergency medical treatment is carried out with immediate effect without
any delay after the cause of the brain damage is confirmed using advanced
imaging techniques.
 The relatives of the patients are informed about the condition of the patient
and possible prognosis is explained.
 Nursing staff which is expert in neurological rehabilitation care is recruited.
 Physiotherapy in form of turning, posture maintenance, chest physiotherapy,
passive movements, active movements wherever applicable is started
immediately.
 Relatives of the patient and the nursing staff are taught the basic
physiotherapeutic techniques so that it can be followed out from time to
time and avoid complications like bed sore, deep vein thrombosis, chest
complications, stiff joints and tight muscles. Early mobilization will help
the brain to learn motor activities rapidly and the sensory system is also
activated.
 Adjunct therapy like the PNF, Bobath techniques, etc. is started as soon
as possible.
 Early weight-bearing on the lower limbs is started as soon as advised by

the experts.
 Psychiatrist or clinical psychologist is called for a special session with the
patient as well as the relatives of the patient. They are made to understand
the problem and they are made ready to face the newer challenges.
 The rehabilitation professionals give the introduction of the entire team
members to the patient and the relatives and their importance is laid down
upon.
 Other team members like the orthotist and the occupational therapist take
up their assessment sessions and the required things are done.
 The relatives of the patient are educated regarding the value of recreation
for the patient as it will make the hospital stay for the patient easy. It
will also make the hospital stay of the relatives fun-filled and stress-free.
 If the patient is fit for discharge from the hospital, they can be taken to
patient’s residence or a transient care unit.
 The transient care unit may be located in the hospital premises or can
be at any other place. Here, the medical staff sees the patient say once
a day or once in two days and the rehabilitation professionals take up
the treatment charge.
 If the patient is shifted to one’s own residence, then they are treated at
home by the physiotherapist. The therapist usually coordinates the entire
rehabilitation program and each other team member is referred time to time
for expert advice.
 As soon as the patient is able to walk and come out of the house, he
is encouraged to go to a rehabilitation clinic, as, he may meet several other
hemiplegia sufferers and they may have a chance to interact with them.
This will induce a feeling of confidence in them.
 All the advanced techniques of physiotherapy and rehabilitation are told
to the patient and hence, best of the treatment can be availed by the patient
timely.
 Time to time clinical psychologist’s session is organized for the patient’s
mental health.
 Vocational guidance is given to the patient in a realistic manner but care
is taken that it has a positive effect on the patient and patient’s morale
boosts up.
 Patients are told about the problems they may face on the social front
and are taught the ways to tackle it.
 Assessment of all the functions is done by the experts on a regular basis
and the therapy is modified as and when required.
Conclusion 431
 If need be, a video or still photographical data of the patient’s initial symptoms
is kept for comparison with the later stages.
 Patient is encouraged to carry out each and every activity of the premorbid
state as and when the time comes and help is given where applicable and
needed.
 The patient is taught to become independent in every aspect and is taught
to become independent of the rehabilitation team, because they have to
learn to manage their life on their own.
 Patient is educated regarding the prognosis in a realistic manner and realistic
goals are set for the patient. These goals are the short term and the long
term goals.
 The patient may be off therapy when the patient is fully rehabilitated in
every aspect in a holistic manner.
The entire process of rehabilitation can be carried out in a more organized
manner if the patient after taking discharge from the hospital is directly shifted
to a rehabilitation hospital or a rehabilitation care center.
This rehabilitation hospital has to have all the rehabilitation services under
one roof and hence, the patient will get all the consultations at one place
only. The coordination between the rehabilitation team members would be
excellent and the responsibilities are shared without any member becoming
complacent.
The patient goes through the entire rehab process at one place which will
save a lot of time and it would be extremely convenient. This rehab hospital
may be a costly affair economically, but as they say, ‘no amount of money
is as important as one’s health’, and truly, ‘health is wealth’.
Standardization of Treatment Techniques

Treatment protocol and the physiotherapy techniques used for the patients suffering
from hemiplegia need to be standardized in India with an immediate effect.
The treatment program is not standardized and hence, at various places, different
techniques are used. This does not ensure a uniform approach and the patients
get confused by this. The rate of recovery also differs and hence, discussion
of prognosis with the patient becomes difficult. It is true that all the centers
of treatment providers cannot have same protocol, as all the patients are different
and need different way of approach. But, at the same time, presently, there
is a complete lack of a proper protocol for the patients. This leads to a very
vague treatment sessions at many places. Thus, patient has to totally depend
upon the treating person and his power of discretion and dedication rather than
patient having to depend upon the science of physiotherapy.
Standardization of treatment techniques will require some amount of ground

work for the research fellows. It may be a difficult affair, but is not impossible.
The best place to start the standardization is targeting the educational institutions.
If physiotherapy students who are future torch bearers of the field of neuro-
rehabilitation are trained from their colleges in the standardized protocol for
hemiplegics, they are bound to implement these techniques in the practice.
For professional physiotherapists, CME programs on a nationwide scale would
ensure an insight into the standardization of the technique. If this is implemented,
there would be evidence-based practice which is the order of the day and
all the patients regardless of their geographical location, would receive the
best rehabilitation treatment.
This author strongly supports the idea of standardization in all treatment
approaches of physiotherapy and recommends the above mentioned steps towards
achieving this goal together.
Ethics and Values in Treatment

In any field of patient care, the importance of the ethics and values is of
paramount importance. Ethics are the moral principles or the moral values
on which the human life is based upon. In India we call it ‘dharma’, the
righteous action. As humans, we like others to behave in a certain manner
with us; like no one should speak untruth with us, no one should cause harm
to us, etc. If we behave in the manner which we like ourselves to be behaved
with, it becomes ethical or moral conduct for us.
Patient care, especially in neurological cases, demands a great deal of ethical
practice. The patients who come for the treatment come with lots of hope.
At this time, it is the duty of the treatment provider to adhere to the basic
values of the life and treat the patient truthfully. It is the duty of the care
taker to explain the exact diagnosis, treatment program and prognosis to the
patient. The treatment provider should first understand his or her own limitations
and strengths and second, he or she should convey this to the patient concerned.
If there are limitations in treating the patient, then, the patient should be referred
to the expert without the delay.
A balance between the earning in terms of money and service to the society
should be maintained for healthy system of healthcare. The clinician should
refrain oneself from the glittering world of malpractice at all costs. He should
not indulge in bogus referrals as this creates an everlasting ill impression
in the minds of the patients for the entire medical and healthcare fraternity.
Last but not the least, the patient should be seen as a human being and should
not be treated as a case or a part of it.
Conclusion 433
Honesty towards the patient and the profession at large will make the society
and the system of healthcare, readily acceptable to one and all, will provide
comfort, care, love, support and compassion along with the treatment which
is being administered.
C H A P T E R
21
Assessment Scores and
Scales
ABCD SCORE
It is used to predict the risk of stroke during the first seven days after a
TIA. Researchers found there to be over 30% risk of stroke in TIA patients
with an ‘ABCD score’ of six, as compared to no strokes in those with a
low ABCD score. Can be used in routine clinical practice to identify high-
risk individuals who require emergency investigation and treatment.
Risk factor Category Score
A Age of patient Age 60 1
Age <60
B Blood pressure at SBP >140 or DBP 90 0
assessment other
C Clinical features Unilateral weakness 2
presented with Speech disturbances (no weakness) 1
Other 0
D Duration of TIA 60 minutes 2
symptoms 10–59 minutes 1
>10 minutes 0
TOTAL 6
Reference
1. Rothwell P, Giles M, Flossmann E, Lovelock C, Redgrave J, Warlow C, et al. A
simple tool to identify individuals at high early risk of stroke after a transient ischaemic
attack: The ABCD score. The Lancet. 2005;366:29-36.
Assessment Scores and Scales 435
THE BARTHEL INDEX

Patient Name: _______________________________________________
Rater Name: _________________________________________________
Date: _______________________________________________________
Activity Score
Feeding
0 = unable
5 = needs help cutting, spreading butter, etc., or requires modified diet
10 = independent _______
Bathing
0 = dependent
5 = independent (or in shower) _______
Grooming
0 = needs to help with personal care
5 = independent face/hair/teeth/shaving (implements provided) _______
Dressing
0 = dependent
5 = needs help but can do about half unaided
10 = independent (including buttons, zips, laces, etc. _______
Bowels
0 = incontinent (or needs to be given enemas)
5 = occasional accident
10 = continent _______
Bladder
0 = incontinent, or catheterized and unable to manage alone
5 = occasional accident
10 = continent _______
Toilet Use
0 = dependent
5 = needs some help, but can do something alone
10 = independent (on and off, dressing, wiping) _______
Transfers (bed to chair and back)

0 = unable, no sitting balance
5 = major help (one or two people, physical), can sit
10 = minor help (verbal or physical)
Mobility (on level surfaces)

0 = immobile or >50 yards
5 = wheelchair independent, including corners, >50 yards
10 = walks with help of one person (verbal or physical) >50 yards
15 = independent (but may use any aid; for example, stick) >50 yards
_______
Stairs
0 = unable
5 = needs help (verbal, physical, carrying aid)
TOTAL (0–100) _______
The Barthel ADL Index: Guidelines

1. The index should be used as a record of what a patient does, not as a
record of what a patient could do.
2. The main aim is to establish degree of independent from any help, physical
or verbal, however, minor and for whatever reason.
3. The need for supervision renders the patient not independent.
4. A patient’s performance should be established using the best available
evidence. Asking the patient, friends/relatives and nurses are the usual sources,
but direct observation and common senses are also important. However,
direct testing is not needed.
5. Usually the patient’s performance over the preceding 24–48 hours is important,
but occasionally longer periods will be relevant.
6. Middle categories imply that the patient supplies over 50% of the effort.
7. Use of aids to be independent is allowed.
References
1. Mahoney FI, Barthel D. Functional evaluation: The Barthel Index. Maryland State
Medical Journal. 1965;14:56-61. Used with permission.
2. Loewen SC, Anderson BA. Predictors of stroke outcome using objective measurement
scales. Stoke. 1990;21:78-81.
3. Greshman GE, Philips TF, Labi ML. ADL status in stroke: Relative merits of three
standard indexes. Arch Phys Med Rehabil. 1980;61:355-8.
4. Collin C, Wade DT, Davies S, Home V. The Barthel ADL Index: A reliability study.
Int Disability study. 1988;10:61-3.
BECK’S DEPRESSION INVENTORY

This depression inventory can be self-scored. The scoring scale is at the end
of the questionnaire.
1. 0 I do not feel sad.
1 I feed sad.
2 I am sad all the time and I cannot snap out of it.
3 I am so sad and unhappy that I cannot stand it.
2. 0 I am not particularly discouraged about the future.
1 I feel discouraged about the future.
2 I feel I have nothing to look forward to.
3 I feel the future is hopeless and that things cannot improve.
3. 0 I do not feel like a failure.
1 I feel I have failed more than the average person.
2 As I look back on my life, all I can see is a lot of failures.
3 I feel I am a complete failure as a person.
4. 0 I get as much satisfaction out of things as I used to.
1 I do not enjoy things the way I used to.
2 I do not get real satisfaction out of anything anymore.
3 I am dissatisfied or bored with everything.
5. 0 I do not feel particularly guilty.
1 I feel guilty a good part of the time.
2 I feel quite guilty most of the time.
3 I feel guilty all the time.
6. 0 I do not feel I am being punished.
1 I feel I may be punished.
2 I expect to be punished.
3 I feel I am being punished.
7. 0 I do not feel disappointed in myself.

1 I am disappointed in myself.
2 I am disgusted with myself.
3 I hate myself.
8. 0 I do not feel I am any worse than anybody else.
1 I am critical of myself for my weaknesses or mistakes.
2 I blame myself all the time for my faults.
3 I blame myself for everything bad that happens.
9. 0 I do not have any thoughts of killing myself.
1 I have thoughts of killing myself, but I would not carry them out.
2 I would like to kill myself.
3 I would kill myself if I had the chance.
10. 0 I do not cry any more than usual.
1 I cry more now than I used to.
2 I cry all the time now.
3 I used to be able to cry, but now I cannot cry even though I want
to.
11. 0 I am no more irritated by things than I ever was.
1 I am slightly more irritated now than usual.
2 I am quite annoyed or irritated a good deal of the time.
3 I feel irritated all the time.
12. 0 I have not lost interest in other people.
1 I am less interested in other people than I used to be.
2 I have lost most of my interest in other people.
3 I have lost all of my interest in other people.
13. 0 I make decision about as well as I ever could.
1 I put off making decisions more than I used to.
2 I have greater difficulty in making decisions more than I used to.
3 I cannot make decisions at all anymore.
14. 0 I do not feel that I look any worse than I used to.
1 I am worried that I am looking old or unattractive.
2 I feel there are permanent changes in my appearance that make
me look unattractive.
3 I believe that I look ugly.
15. 0 I can work about as well as before.
1 It takes an extra effort to get started at doing something.
2 I have to push myself very hard to do anything.
3 I cannot do any work at all.
16. 0 I can sleep as well as usual.

1 I do not sleep as well as I used to.
2 I wake up 1–2 hours earlier than usual and find it hard to get
back to sleep.
3 I wake up several hours earlier than I used and cannot get back
to sleep.
17. 0 I do not get more tired than usual.
1 It takes an extra effort to get started at doing something.
2 I have to push myself very hard to do anything.
3 I am too tired to do anything.
18. 0 My appetite is no worse than usual.
1 My appetite is not as good as it used to be.
2 My appetite is much worse now.
3 I have no appetite at all anymore.
19. 0 I have not lost much weight, if any, lately.
1 I have lost more than five pounds.
2 I have lost more than ten pounds.
3 I have lost more than fifteen pounds.
20. 0 I am no more worried about my health than usual.
1 I am worried about physical problems like aches, pains, upset
stomach, or constipation.
2 I am very worried about physical problems and it is hard to think
of much else.
3 I am so worried about my physical problems that I cannot think
of anything else.
21. 0 I have not noticed any recent change in my interest in sex.
1 I am less interested in sex than I used to be.
2 I have almost no interest in sex.
3 I have lost interest in sex completely.
Interpreting the Beck’s Depression Inventory

Now that you have completed the questionnaire, add up the score for each
of the twenty-one questions by counting the number of right of each question
you marked. The highest possible total for the whole test would be sixty-
three. This would mean you circled number three on all twenty-one questions.
Since the lowest possible score for each question is zero, the lowest possible
score for the test would be zero. This would mean you circles zero on each
question.
Total score Levels of depression

1–10 These ups and downs are considered normal
11–16 Mild mood disturbances
17–20 Borderline clinical depression
21–30 Moderate depression
31–40 Severe depression
Over 40 Extreme depression
A persistent score of 17 or above indicates that you may need medical
treatment.
BERG BALANCE SCALE

Patient Name:
Rater Name:
Date:
Balance item
Score (0–4)
1. Sitting unsupported
2. Change of position: Sitting to standing ________
3. Change of position: Standing to sitting ________
4. Transfers ________
5. Standing unsupported ________
6. Standing with eyes closed ________
7. Standing with feet together ________
8. Tandem standing ________
9. Standing on one leg ________
10. Turning trunk (feet fixed) ________
11. Retrieving objects from floor ________
12. Turning 360 degrees ________
13. Stool stepping ________
14. Reaching forward while standing ________
TOTAL (0–56): ________
Interpretation
0–20, wheelchair bound
21–40, walking with assistance
41–56, independent
References
1. Berg K, Wood-Dauphinee S, Williams JI, Maki, B. Measuring balance in the elderly:
Validation of an instrument. Can J Pub Health, July/August supplements 1992;2:57-
11.
2. Berg K, Wood-Dauphinee S, Williams JI, Gsyton. Measuring balance in the elderly:
Preliminary development of an instrument: Physiotherapy. Canada.1989;41:304-11.
CANADIAN NEUROLOGICAL SCALE

Patient Name: _________________________________________________
Rater Name: ___________________________________________________
Date: _________________________________________________________
Mentation Score
Level consciousness Alert 3.0
Drowsy 1.5
Orientation Oriented 1.0
Disoriented/NA 0.0
Speech Normal 1.0
Expressive Deficit 0.5
Receptive Deficit 0.0
TOTAL: __________
Section A1 Motor Functions Weakness Score
NO Face None 0.5

COMPREHENSIVE Present 0.0
DEFICIT Arm: Proximal None 1.5
Mild 1.0
Significant 0.5
Total 0
Arm: Distal None 1.5
Mild 1.0
Significant 0.5
Total 0
Leg: Proximal None 1.5
Mild 1.0
Significant 0.5
Total 0
Leg: Distal None 1.5

Mild 1.0
Significant 0.5
Total 0
TOTAL: _________
NO Face Symmetrical 0.5
COMPREHENSIVE Asymmetrical 0.0
DEFICIT Arm Equal 1.5
Unequal 0.0
Leg Equal 1.5
Unequal 0.0
TOTAL: _______
References
1. CoteR, Hachinski VC, Shurvell BL, Norris JW, Wolfson C. The Canadian Neurological:
Scale A preliminary study in acute stoke. Stroke. 1986;17:731–37.
2. Cote R, Battista RN, Wolfson C, Bouncher J, Hachinski VC. The Canadian Neurological:
Scale Validation and reliability assessment. Neurology. 1989;39:638–43.
CINCINNATI PREHOSPITAL STROKE SCALE

Facial Drop
Normal: Both sides of the face move equally
Abnormally: One side of face does not move at all
Arm Drift
Normal:Both arms move equally or not at all
Abnormally: One arm drifts compared to the other
Speech
Normal:Patient uses correct words with no slurring
Abnormally: Slurred or inappropriate words or mute
References
1. Kothari RU, Pancioli A, Liu T, Brott T, Broderick J. Cincinnati Prehospital Stroke
Scale: Reproducibility and validity. Ann Emerg Med. 1999;33(4):373-8.
THE EUROPEAN STROKE SCALE

Overview
The European stroke scale can be used to assess a patient who has recently
had a stroke involving the distribution of a middle cerebral artery. This can
be used to measure therapeutic efficacy and to match patients for comparison.
Parameters
1. Level of consciousness.
2. Comprehension: The patient is asked to follow these commands: (a) Stick
out tongue, (b) put a figure from the (unaffected) side to the nose, (c)
close the eyelids, the examiner must not demonstrate the action.
3. Speech: The examiner makes general conversation with the patient.
4. Visual field: The examiner stands at the arm’s length and compares the
patient’s field of vision by advancing a moving finger from the periphery
inwards. The patient is asked to fixate on the examiner’s pupil. The
test is done first with one eye open and other closed, then the opposite.
5. Gaze: The examiner steadies the patient’s head and asks the patient to
follow the examiner’s finger. The examiner observes the resting eye position
and subsequently, the full range of movements by moving the finger
from the left to the right, then vice versa.
6. Facial movements: The patient’s face is examined while talking and smiling,
with any asymmetries noted. Only the muscles in the lower half of the
face are assessed.
7. Arm in outstretched position: The patient is asked to close the eyes.
The patient’s arms are actively lifted into a 45° position relative to the
horizontal plane, with both hands in mid-position facing each other. The
patient is asked to maintain this position for 5 seconds after the examiner
withdraws the support. Only the affected side is evaluated.
8. Arm raising: The patient’s arm is rested next to the leg with the hand
in mid-position. The patient is asked to raise the arm outstretched to
90° (vertical).
9. Extension of wrist: The patient is tested with the forearm supported.
The hand is unsupported but relaxed in pronation. The patient is to extend
the hand.
10. Fingers: The patient is asked to form a pinch grip with the thumb and
forefinger and to resist a weak pull. The examiner assesses the strength
of the pinch grip by pulling on the pinched fingers using one finger.
11. Leg maintained in position: The examiner actively lifts the patient’s affected
leg into position, with the thigh perpendicular to the bed and the lower
leg parallel to the bed, the patient is asked to close the eyes and to
maintain the leg in position for five seconds without support.
12. Leg flexing: The patient is supine with the leg outstretched. The patient
is asked to flex the hip and knee.
13. Dorsiflexion of foot: The patient’s leg is outstretched, with the patient
asked to dorsiflex the foot.
14. Gait.
Parameter Findings Points
Level of Alert, keenly responsive 10
consciousness
Drowsy but can be aroused by minor
stimulation to obey, answer or respond 8
Requires repeated stimulation to attend,
or is lethargic or obtunded, requiring
strong or painful stimulation to make
movements 6
Cannot be roused by any stimulation,
does react purposefully to painful stimuli 4
does react with decerebration to
painful stimuli 2
does not react to painful stimuli 0
Comprehension Patients perform 3 commands 8
Patients perform 1 or 2 commands 4
Patient does not perform any command 0
Speech Normal speech 8
Slight word-finding difficulty, conversation
is possible 6
Severe word-finding difficulties,
conversation is difficult 4
Only yes or no 2
Mute 0
Visual field Normal 8

Deficit 0
Gaze Normal 8
Median eye position, deviation to one
side impossible 4
Later eye position, return to midline possible 2
Later eye position, return to midline impossible 0
Facial movement Normal 8
Paresis 4
Paralysis 0
Arm (ability to Arm maintaining position for 5 seconds 4
maintain out-
stretched
position)
Arm maintained position for 5 seconds
but affected hand pronates 3
Arm drifts before 5 seconds pass and
maintains lower position 2
Arm cannot maintain position but attempts
to oppose gravity 1
Arm falls 0
Arm (raising) Normal 4
Straight arm, movement not full 3
Flexed arm 2
Trace movements 1
No movements 0
Extension of Normal (full isolated movement,
the wrist no decrease in strength) 8
Full isolated movement, reduced strength 6
Movement not isolated and/or full 4
Trace movements 2
No movement 0
Fingers Equal strength 8
Reduced strength on affected side 4
Pinch grip impossible on affected side 0
Leg (maintain Leg maintains position for 5 seconds 4

position)
Leg drifts to intermediate position by the
end of 5 seconds 2
Leg drifts to bed within 5 seconds
but not immediately 1
Leg falls to bed immediately 0
Leg (flexing) Normal 4
Movement against resistance, reduced strength 3
Movement against gravity 2
Trace movements 1
No movements 0
Dorsiflexion Normal (leg outstretched, full movement,
of foot no decrease in strength) 8
Leg outstretched, full movement, reduced strength 6
Leg outstretched, movement not full or knee
flexed or foot in supination 4
Trace movements 2
No movement 0
Gait Normal 10
Gait has abnormal aspect and/or distance
limited and/or speed limited 8
Patient can walk with aid 6
Patient can walk with physical assistance
of one or more persons 4
Patient cannot walk but can stand unsupported 2
Patient cannot stand nor walk 0
European stroke score = SUM (points for all 14 parameters)

Interpretation:
 Minimum score: 0
 Maximum score: 100
 A completely normal person would have a score of 100.
 The maximum affected person has a score of 0.
Reference
1. Hanston L, De Weerdt W, et al. The European Stroke Scale. Stroke. 1994;25:2215-
19.
FAMILY ASSESSMENT DEVICE

1. Nathan B, Epstein, MD; Lawrence M Baldwin, PhD; Duane S Bishop, MD.
Instructions
This assessment contains a number of statements about families. Read each
statement carefully and decide how well it describes your own family. You
should answer according to how you see your family.
For each statement are four (4) possible responses:

Strongly agree (SA) Check SA if you feel that the statement describes
your family very accurately.
Agree (A) Check A if you feel that the statement describes your
family for the most part.
Disagree (D) Check D if you feel that the statement does not
describes your family for the most part.
Strongly disagree (SD) Check SD if you feel that the statement does not
describe your family at all.
For each statement, there is an answer space below. Do not pay attention
to the blanks at the far right-hand side of each space.
Try not to spend too much time thinking about each statement, but respond
as quickly and as honestly as you can. If you have difficulty, answer with
your first reaction. Please be sure to answer every statement and mark all
your answers in the space provided below each statement.
1. Planning family activities is difficult because we misunderstand each
other.
______ SA_______A________D_________SD__________
2. We resolve most everyday problems around the house.
______ SA_______A________D_________SD__________
3. When someone is upset the other knows why.
______ SA_______A________D_________SD__________
4. When you ask someone to do something, you have to check that they
did it.
______ SA_______A________D_________SD__________
5. If someone is in trouble, the others become too involved.
______ SA_______A________D_________SD__________
6. In times of crisis, we can turn each other for the support.
______ SA_______A________D_________SD__________
7. We don’t know what to do when an emergency comes up.
______ SA_______A________D_________SD__________
8. We sometimes run out of the things that we need.
______ SA_______A________D_________SD__________
9. We are reluctant to show our affection for each other.
______ SA_______A________D_________SD__________
10. We make sure members meet their family responsibilities.
______ SA_______A________D_________SD__________
11. We cannot talk to each other about the sadness we feel.
______ SA_______A________D_________SD__________
12. We usually act on our decisions regarding problems.
______ SA_______A________D_________SD__________
13. You only get the interest of others when something is important to them.
______ SA_______A________D_________SD__________
14. You can’t tell how a person is feeling from what they are saying.
______ SA_______A________D _________SD_________
15. Family tasks don’t get spread around enough.
______ SA_______A________D_________SD__________
16. Individuals are accepted for what they are.
______ SA_______A________D_________SD__________
17. You can easily get away with breaking the rules.
______ SA_______A________D_________SD__________
18. People come right out and say things instead of hinting at them.
______ SA_______A________D_________SD__________
19. Some of us just don’t respond emotionally.
______ SA_______A________D_________SD__________
20. We know what to do in an emergency.
______ SA_______A________D_________SD__________
21. We avoid discussing our fears and concerns.
______ SA_______A________D_________SD__________
22. It is difficult to talk to each other about tender feelings.
______ SA_______A________D_________SD__________
23. We have trouble meeting our financial obligations.
______ SA_______A________D_________SD__________
24. After our family to solve a problem, we usually discuss whether it worked
or not.
______ SA_______A________D_________SD__________
25. We are too self-centered.
______ SA_______A________D_________SD__________
26. We can express feelings to each other.
______ SA_______A________D_________SD__________
27. We have no clear expectations about toilet habits.
______ SA_______A________D_________SD__________
28. We do not show our love for each other.
______ SA_______A________D_________SD__________
29. We talk to people directly rather than through go-betweens.
______ SA_______A________D_________SD__________
30. Each of us has particular duties and responsibilities.

______ SA_______A________D_________SD__________
31. There are lots of bad feelings in the family.
______ SA_______A________D_________SD__________
32. We have rules about hitting people.
______ SA_______A________D_________SD__________
33. We get involved with each other only when something interests us.
______ SA_______A________D_________SD__________
34. There is little time to explore personal interests.
______ SA_______A________D_________SD__________
35. We often don’t say what we mean.
______ SA_______A________D_________SD__________
36. We feel accepted for what we are.
______ SA_______A________D_________SD__________
37. We show interest in each other when we can get something out of it
personally.
______ SA_______A________D_________SD__________
38. We resolve most emotional upset that come up.
______ SA_______A________D_________SD__________
39. Tenderness takes second place to other things in our family.
______ SA_______A________D_________SD__________
40. We discuss who are responsible for household jobs.
______ SA_______A________D_________SD __________
41. Making decisions is a problem for our family.
______ SA_______A________D_________SD __________
42. Our family shows interest in each other only when they can get something
out of it.
______ SA_______A________D_________SD __________
43. We are frank (direct, straightforward) with each other.

______ SA_______A________D_________SD __________
44. We don’t hold to any rules or standards.
______ SA_______A________D_________SD __________
45. If people are asked to do something, they need reminding.
______ SA_______A________D_________SD __________
46. We are able to make decisions about how to solve problems.
______ SA_______A________D_________SD __________
47. If the rules are broken, we don’t know what to expect.
______ SA_______A________D_________SD __________
48. Anything goes in our family.
______ SA_______A________D_________SD __________
49. We express tenderness.
______ SA_______A________D_________SD __________
50. We confront problems involving feelings.
______ SA_______A________D_________SD __________
51. We don’t get along well together.
______ SA_______A________D_________SD __________
52. We don’t talk to each other when we are angry.
______ SA_______A________D_________SD __________
53. We are generally dissatisfied with the family duties assigned to us.
______ SA_______A________D_________SD__________
54. Even though we mean well, we intrude too much into each other’s lives.
______ SA_______A________D_________SD__________
55. There are rules in our family about dangerous situations.
______ SA_______A________D_________SD__________
56. We confide in each other.
______ SA_______A________D_________SD__________
57. We cry openly.

______ SA_______A________D_________SD__________
58. We do not have reasonable transport.
______ SA_______A________D_________SD__________
59. When we do not like what someone has done, we tell them.
______ SA_______A________D_________SD__________
60. We try to think of different ways to solve problems.
______ SA_______A________D_________SD__________
Suggested Terminology for Objective Data

(Evaluation Criteria)
Levels of Functional Skills
Assistance
Complete All of the tasks described as making up the activity
independence are typically performed safely, without modification,
(FIM 7) assistive devices, or aids, and within a reasonable time; no
assistance required. Performs activity safely alone and feels
secure.
Modified One or more of the following may be true: the activity
Independence requires an assistive device; the activity takes more than
(FIM 6) reasonable time, or these are safety (risk) considerations;
not manual assistance/helper required.
Supervision or Patient requires no more help than standby, cueing
Setup (FIM 5) or coaxing, without physical contact, or, someone is needed
to set up needed items or apply orthoses; requires supervision
and/or verbal cues to complete activity (may not always be
done safely or correctly).
Contact Guarding A variation of minimal assist where patient requires occasional
contact to maintain balance or dynamic stability; requires
hand contact because of occasional loss of balance (protective
safeguard)
Minimal (contact) Patient requires small amount of help accomplish
assistance (FIM 4) activity; patient requires no more help than touching, and
expends 75% or more of the effort. Patient is able to assume
all of his body weight, but requires guidance for initiation,
balance, and/or stability during the activity.
Moderate Assistance Patient requires more help than touching; expands
(FIM3) half (50%) or more (up to 75%) of the effort. Patient is able
to assume part of his body weight in initiating and performing
the activity.
Maximal Assistance Patient contributes little or nothing towards execution

(FIM 2) of activity; patient expands less than 50% of the effort, but
at least 25%.
Total Assistance (FIM1) Patient lacks the necessary strength or mental capability to
perform any part of the activity or performance is impractical;
patient expends less than 25% of the effort. Patient is unable
to safely initiate and/or perform any part of the activity on
his own.
References
1. Definitions were partially taken from guide for the uniform data set for medical
rehabilitation (adult functional independence measure (FIM). Version 4.0. Buffalo,
NY 14214: State University of New York at Buffalo. 1993.
2. O’ Sullivan, Schmitz. Physical Rehabilitation: Assessment and Treatment (4th edn).
Philadelphia: FA Davis Company, 2001.pp. 5-6.
Regarding Assistance:
The patient may require more than person and varying amounts of assistance
(for example, maximum assist and minimum assist of one). Always document
the type of activity, number of people required for assistance, and the amount
of assistance given by those assisting.
THE FRENCHAY ACTIVITIES INDEX

Items Code
In the last 3 months
 preparing main meals 1 = never
 washing up 2 time per week
3 = 1–2 times per week
4 = most days
 Washing clothes 1 = never
 Light housework 2 = 1–2 times in 3 months
 Heavy housework 3 = 3-12 times in 3 months
 Local shopping 41 time per week
 Social outings
 Walking outside >15 minutes
 Actively pursuing hobby
 Driving car/bus travel
In the last 6 months

 Outings/car rides 1 = never
2 = 1–2 times in 6 months
3 = 3–12 times in 6 months

4 = 0.1 time per week
 Gardening 1 = never
 Household/car maintenance 2 = light
3 = moderate
4 = all necessary
 Reading books 1 = none
2 = 1 in 6 months
3 in 2 weeks
4 1 in 2 weeks
 Gainful work 1 = none
210 hour/week
3 = 10–30 hour/week
430 hour/week
GERIATRIC DEPRESSION SCALE (SHORT FORM)

Patient’s name: __________________________ Date: ______________
Instructions: Choose the best answer for how you feel over the past week.
No. Question Answer Score
1. Are you basically satisfied with your life? Yes/No –
2. Have you dropped many of your activities and
interests? Yes/No
3. Do you feel that life is empty? Yes/No –
4. Do you often get bored? Yes/No –
5. Are you in good spirits most of the time? Yes/No –
6. Are you afraid that something bad is going to
happen to you? Yes/No –
7. Do you feel happy most of the time? Yes/No –
8. Do you often feel helpless? Yes/No –
9. Do you prefer to stay at home, rather than
going out and doing new things? Yes/No –
10. Do you feel you have more problems with
memory than most? Yes/No –
11. Do you think it is wonderful to be alive? Yes/No –
12. Do you feel pretty worthless the way you are now? Yes/No –
13. Do you feel full of energy? Yes/No –
14. Do you feel that your situation is hopeless? Yes/No –
15. Do you think that most people are better

off than you are? Yes/No –
TOTAL
Scoring
Assign one point for each of these answers:
1. No 4. Yes 7. No 10. Yes 13. No
2. Yes 5. No 8. Yes 11. No 14. Yes
3. Yes 6. No 9. Yes 12. Yes 15. Yes
A score of 0 to 5 is normal. A score above 5 suggests depression.
References
1. Yesavage JA, Brink TL, et al. Development and validation of a geriatric depression
screening scale: A preliminary report. J Psychiatr Res. 1983;17:37-49.
GLASGOW COMA SCALE

Patient Name: ________________________________________________
Rater Name: __________________________________________________
Date: ________________________________________________________
Activity Score
Eye Opening
None 1 = Even to supraorbital pressure __________
To pain 2 = Pain from sternum/limb/supraorbital
pressure __________
To speech 3 = Nonspecific response, not necessarily
to command __________
Spontaneous 4 = Eyes open, not necessarily aware __________
Motor Response
None 1 = To any pain; limbs remain flaccid __________
Extension 2 = Shoulder adducted and shoulder
and forearm internally rotated __________
Flexor response 3 = Withdrawal response or assumption
of hemiplegic posture __________
Withdrawal 4 = Arm withdraws to pain,

shoulder abducts __________
Localizes pain 5 = Arm attempts to remove
supra-orbital/chest pressure __________
Obeys commands 6 = Follows simple commands __________
Verbal Response
None 1 = No verbalization of any type
Incomprehensible 2 = Moans/groans, no speech
Inappropriate 3 = Intelligible, no sustained sentences
Confused 4 = Converses but confused, disoriented
Oriented 5 = Converses and oriented. __________
TOTAL (3–15): __________
References
1. Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical
scale. The Lancet. 1974;13;2(7872):81-4.
HEMISPHERIC STROKE SCALE

Patient Name: _________________________________________________
Rater Name: _________________________________________________
Date: _________________________________________________
Scored to give 0 (good) to 100 (bad)
Levels of Consciousness Score

15-Glasgow Coma Scale Score __________
Language
Comprehension
Give three commands:
• ‘Stick out your tongue’ or ‘close your eyes’
• ‘Point to the door’
• ‘Place left/right hand on left/right ear and then on left/right knee (using
unaffected side)
Score on number correctly followed:
0 = 5
1 = 4
2 = 2
3 = 0
Naming
Ask patient to name the following items:
• Watch or belt
• Watch strap or belt buckle
• Index finger or ring finger
Score on number correctly named:
0 = 5
1 = 4
2 = 2
3 = 0
Repetition
Ask the patient to repeat the following:
• A single word, such as ‘dog’ or ‘cat’
• ‘The president lives in Washington’
• ‘No ifs, ands, or buts’
Score on number repeated:
0 = 5
1 = 4
2 = 2
3 = 0
Fluency
Score according to patient’s spontaneous speech fluency,
or
Ask patient to name as many words as he can within one minute beginning
with the letter ‘A’ (excluding proper names)
Score as:
5 = Essentially no verbal output
3 = Moderately loss; inability to recognize stationary
finger, sees moving finger
1 = Mild loss; defect to double simultaneous stimulation
0 = Normal
Page 1 TOTAL __________
Other Cortical Functions and Cranial Nerves

Visual Fields _______
Test clinically and score hemi-field loss as:
3 = Severe loss; inability to recognize moving hand, no response to threat
2 = Moderate loss; inability to recognize stationary finger, sees moving
finger
1 = Mild loss: Defect to double simultaneous stimulation
0 = Normal
Gaze
Score eye movements:
2 = Gaze play, or persistent deviation
1 = Gaze preference, or difficulty with far lateral gaze
0 = Normal
Facial expression _______

Score movements:
3 = Severe weakness; drooling
2 = Moderate loss; asymmetry at rest
1 = Mild weakness; asymmetry on smiling
0 = Normal
Dysarthia _______
Score talking:
2 = Severe dysarthria
1 = Moderate dysarthria
0 = Normal
Page 2 TOTAL: __________
Neglect Syndrome
Ask about weak limbs, and ask to bisect a line 20 cm long on piece of paper
in visual midline
Score:
2 = Anosagnosia, or denial of body part
1 = Consistently bisects line towards ‘good’ side of body
0 = Bisects line in middle
Visual Construction _______

Ask patient to copy three figure given, and score:
3 = Unable to copy any finger
2 = Can copy a square
1 = Can copy a ‘Greek Cross’ (Cross of St. George)
0 = Can copy 3D drawing of cube
Motor Fuction
Arm, proximal __________
Arm, distal __________
Leg, proximal __________
Leg, distal __________
All scored 0–7 as:

7 = No movement (MRC 0)
6 = Trace movement only (MRC 1)
5 = Motion without gravity only (MRC 2)
4 = Moves against gravity but not against
resistance (MRC 3)
3 = Moderate weakness (MRC 4)
2 = Mild weakness (MRC 4)
Page TOTAL: __________
1 = Positive drift of arm/leg (MRC 4+)
0 = Normal (MRC 5)
Deep Tendon Reflexes ________

2 = Hypoactive or hyperactive
0 = Normal
Pathological Reflexes ________

2 = Babinski (plantar) and another abnormal
1 = Babinski (plantar) and another abnormal
0 = Normal
Muscle Tone ________

2 = Increased or decreased
0 = Normal
Gait ________
Test ability to stand and walk, and score:
6 = Unable to stand unsupported or cannot evaluate
5 = Can stand with support but cannot walk
4 = Severe abnormal; walking distance limited even
with support (from aid or person)
3 = Moderately abnormal; no assistance required
(apart from a stick/cane), but distance limited
2 = mildly abnormal (weak, uncoordinated); can walk
independently but slowly
1 = Minimally abnormal, no reduction in speed or distance
0 = Normal
Page 3 TOTAL: __________
Sensory
Primary Modalities (of affected side only), Arm ________
Test touch, pain and score as:
4 = Anesthesia
3 = Severe hyperesthesia
2 = Moderate hyperesthesia or deficit only; or
extinction to double simultaneous stimulation
1 = Mild hyperaesthesia or dysaesthesia
0 = Normal
Stereognosis
Test ability to distinguish two coins and a key, and score:
3 = Unable to achieve any distinctions
2 = Can distinguish a coin from a key
1 = Can distinguish between two very different sized coins
(penny and ten-pence piece, penny and quarter)
0 = Can distinguish between two similar sized coins
(penny and nickel, or two-pence piece and ten-pence piece)
Page 4 TOTAL : __________
OVERALL TOTAL: __________
References
1. Adams RJ, Meador KJ, Sethi KD, Grotta JC, Thomson DS. Graded neurologic scale
for use in acute hemispheric stroke treatment protocols. Stroke. 1987;18:665-9.
HUNT AND HESS SCALE

Patient Name: _________________________________________________
Rater Name: ___________________________________________________
Date: _________________________________________________________
For non-traumatic sub-arachnoid hemorrhage patients

(Choose single most appropriate grade)
Description
Grade
Asymptomatic, mild headache, slight nuchal rigidity 1
Moderate to severe headache, nuchal rigidity, no
neurologic deficit other than cranial nerve palsy 2
Drowsiness/ confusion, mild focal neurologic deficit 3
Stupor, moderate-severe hemiparesis 4
Coma, decerebrate posturing 5
GRADE (1-5):
References
1. Hunt WE, Hess RM. Surgical risk as related to time of intervention in the repair
of intracranial aneurysms. J. Neurosurg. 1968;28(1):14-20.
2. Hunt WE, Meagher JN, Hess RM. Intracranial aneurysm. A nine-year study.
3. Ohio State Med J 1966 Nov;62(11):1168-71.
MATHEW STROKE SCALE

Patient Name: _________________________________________________
Rater Name: ___________________________________________________
Date: _________________________________________________________
Activity Score
Mentation
Level of consciousness
8 = Fully conscious
6 = Lethargic but mentally intact
4 = Obtunded
2 = Stuporous
0 = Comatose
Oriented (time, place, person)
6 = Oriented × 3
4 = Oriented × 2
2 = Oriented × 1
0 = Disoriented
Speech
0–23, according to Halstead-Reitan test __________
Cranial nerves
Homonymous hemianopsia
3 = Intact
2 = Mild
1 = Moderate
0 = Severe
Conjugate deviation of eyes
3 = Intact
2 = Mild
1 = Moderate
0 = Severe
Facial Weakness
3 = Intact
2 = Mild
1 = Moderate
0 = Severe
Motor Power
Right arm __________
Right leg __________
Left arm __________
Left leg __________
5 = Normal strength
4 = Contracts against resistance
3 = Elevates against gravity
2 = Gravity eliminated
1 = Flicker
0 = No movements
Performance, or disability status scale

28 = Normal
21 = Mild impairment
14 = Moderate impairment
7 = Severe impairment
0 = Death
Reflexes
3 = Normal
2 = Asymmetrical or pathological reflexes
1 = Clonus
0 = No reflexes elicited
Sensation
3 = Normal
2 = Mild
1 = Severe sensory abnormality

0 = No response to pain
TOTAL __________
Reference
1. Mathew NT, Rivera VM, Meyer JS, Charney JZ, Hartmann A. Double-blind evaluation
of glycerol therapy in acute cerebral infarction. Lancet.1972;2:1327-9.
MINI-MENTAL STATE EXAMINATION (MMSE)
Patient’s name: ___________________________ Date_____________

Instructions: Score one point for each correct response within each question
or activity.
Maximum Patient’s Questions

Score Score
5 “What is the year? Season? Date? Day? Month?”
5 “Where are we now? State? Country? Town/city?
Hospital? Floor?”
3 The examiner names three unrelated objects clearly
and slowly, then the instructor asks the patient to name
all three of them. The patient’s response is used for
scoring. The examiner repeats them until patient learns
all of them, if possible.
5 “I would like you to count backward from 100 by sevens”
(93, 86, 79, 72, 65,.....); Alternative: “Spell WORLD
backwards.” (D-L-R-O-W)
3 “Earlier I told you the names of three things. Can you
tell me what those were?”
2 Show the patient two simple objects, such as a
wristwatch and a pencil, and ask the patient to name
them.
1 “Repeat the phrase: ‘No ifs, ands, or buts.”
3 “Take the paper in your right hand, fold it in half, and
put it on the floor” (The examiner gives the patient
a piece of blank paper).
1 “Please read this and do what it says.” (Written
instruction is “Close your eyes”).
1 “Make up and write a sentence about anything.” (This

sentence must contain a noun and a verb).
1 “Please copy this picture” (The examiner gives the
patient a blank piece of paper and asks him/her to
draw the symbol below. All 10 angels must be present
and two must intersects).
30 TOTAL
Interpretation of the MMSE:

Method Score Interpretation
Single Cut off >24 Abnormal
Range >21 Increased odds of dementia
>25 Decreased odds of dementia
Education >21 Abnormal for 8th grade education
>23 Abnormal for high school education
>24 Abnormal for college education
Severity 24–30 No cognitive impairment
18–23 Mild cognitive impairment
0–17 Severe cognitive impairment
Interpretation of the MMSE Scores

Score Degree of Formal Psychometric Day-to-Day Functioning
Impairment Assessment
25–30 Questionably If clinical signs of May have clinically
significant cognitive impairment significant but mild deficits.
are present, formal Likely to affect only most
assessment of cognition demanding activities of
may be valuable daily living
20–25 Mild Formal assessment Significant effect. May
may be helpful to require some supervision,
better determine pattern support and assistance
and extent of deficits
10–20 Moderate Formal assessment Clear impairment.
may be helpful if there May require 24-hour
are specific clinical supervision
indications
0–10 Severe Patient not likely Marked impairment. Likely

to be testable to require 24-hour
supervision and assistance
with ADL
References
1. Folstein MF, Folstein SE, McHug PR. Mini-mental state: A practical method for
grading the cognitive state of patients for the clinician. J Psychiatry Res. 1975;12:189-
98.
MODIFIED RANKIN SCALE (MRS)

Patient Name: _________________________________________________
Rater Name: ___________________________________________________
Date: _________________________________________________________
Score Description
0 No symptoms at all
1 No significant disability despite symptoms; able to carry out all
usual duties and activities
2 Slightly disability; unable to carry out all previous activities, but
able to look after own affairs without assistance
3 Moderate disability; requiring some help, but able to walk without
assistance
4 Moderately severe disability; unable to walk without assistance
and unable to attend to own bodily needs without assistance
5 Severe disability; bedridden, incontinent and requiring constant
nursing care and attention
6 Dead.
TOTAL (0–6): ___________
References
1. Rankin J. Cerebral vascular accidents in patients over the age of 60. Scott Med
J. 1957;2:200-15
2. Bonita R, Beaglehole R. Modification of Rankin Scale: Recovery of motor function
after stroke. Stroke. 1998;19(12):1497-500.
3. van Swieten JC, Koudstaal PJ, Visser MC, Schouten HJ, van Gijin J. Interobserver
agreement for the assessment of handicap in stroke patients. Stroke. 1988;19(5):
604-7.
MOTOR ASSESSMENT SCALE

Agency: ______________PID#: ____________Date: _______CPT#:_______
Patient’s name: ________________________ Therapist: ___________________
If the patient cannot complete any part of a section score a zero (0) for
that section. There are 9 sections in all.
Supine to Side-lying onto Intact Side

(Starting position: Supine with knees straight)
1. Uses intact arm to pull body towards intact side. Uses intact leg to hook
impaired leg to pull it over.
2. Actively moves impaired leg across body to roll but leaves impaired arm
behind.
3. Impaired arm is lifted across body with other arm. Impaired leg moves
actively and body follows as a block.
4. Actively moves impaired arm across body. The rest of the moves as a
block.
5. Actively moves impaired arm and leg rolling to intact side but overbalances.
6. Rolls to intact side in 3 seconds without use of hands.
Supine to Sitting over side of bed

1. Assisted to the side-lying position: Patient lifts head sideways but can’t
sit up.
2. May be assisted to side-lying and is assisted to sitting but has head control
throughout.
3. May be assisted to side-lying and is assisted with lowering Les off bed
to assume sitting.
4. May be assisted to side-lying but is able to sit up without help.
5. Able to move from supine to sitting without help.
6. Able to move from supine to sitting without help in 10 seconds.
Balance Sitting
1. Assisted to sitting and needs support to remain sitting.
2. Sits unsupported for 10 seconds with arms folded, knees and feet together
and feet on the floor.
3. Sits unsupported with weight shifted forward and evenly disturbed over
both hips/legs. Head and thoracic spine extended.
4. Sits unsupported with feet together on the floor. Hands resting on thighs.
Without moving the legs the patient turns the head and trunk to look behind
the right and left shoulders.
5. Sits unsupported with feet together on the floor. Without allowing the legs
or feet to move and without holding on, the patient must reach forward
to touch the floor (10 cm or 4 inches in front of them); the affected arm
may be supported if necessary.
6. Sits on stool unsupported with feet on the floor. Patient reaches sideways
without moving the legs or holding on and returns to sitting position. Support
affected arm if needed.
Sitting to Standing
1. Assisted to standing—any method.
2. Assisted to standing. The patient’s weight is unevenly distributed and may
use hands for support.
3. Stands up. The patient’s weight is evenly distributed but hips and knees
are flexed—no use of hands for support.
4. Stands up. Remains standing for 5 seconds with hip and knees extended
with weight evenly distributed.
5. Stands up and sits down again. When standing hips and knees are extended
with weight evenly distributed.
6. Stands up and sits down again three times in 10 seconds with hip and
knees extended and weight evenly distributed.
Walking
1. With assistance, the patient stands on affected leg with the affected weight
bearing hip extended and steps forward with the intact leg.
2. Walks with the assistance of one person.
3. Walks 10 feet or 3 meters without assistance but with an assistive device.
4. Walks 16 feet or 5 meters without a device or assistance in 15 seconds.
5. Walks 33 feet or 10 meters without assistance or a device. Is able to pick
up a small object from the floor with either hand walk back in 25 seconds.
6. Walks up and down 4 steps with or without a device but without holding
onto a rail three times in 35 seconds.
Upper Arm Function

1. Supine: Therapist places affected arm in 90 degrees shoulder flexion and
holds elbow in extension—hand toward ceiling. The patient protracts the
affected shoulder actively.
2. Supine: Therapist places affected arm in above position. The patient must
maintain the position for 2 seconds with some external rotation and with
the elbow in at least 20 degrees of full extension.
3. Supine: Patient assumes above position and brings hand to forehead and
extends again. (flexion and extension of elbow). Therapist may assist with
supination of forearm.
4. Sitting: Therapist places affected arm in 90 degrees of forward flexion.
Patient must hold affected arm in position for 2 seconds with some shoulder
external rotation and forearm supination. No excessive shoulder elevation
or pronation.
5. Sitting: Patient lifts affected arm to 90 degrees forward flexion—holds it
there for 10 seconds and then lowers it with some shoulder external rotation
and forearm supination. No pronation.
6. Standing: Have patient’s affected arm abducted to 90 degrees with palm
flat against wall. Patient must maintain arm position while turning body
towards the wall.
Hand Movements
1. Sitting at a table (wrist extension): Affected forearm resting on table. Place
cylindrical object in palm of patient’s hand. Patient asked to lift object
off the table by extending the wrist—no elbow flexion allowed.
2. Sitting at a table (radial deviation of wrist): Therapist should place forearm
with ulnar side on table in mid-pronation/supination position. Thumb in
line with forearm and wrist in extension. Fingers around cylindrical object.
Patient is asked to lift hand off table. No wrist flexion or extension.
3. Sitting (pronation/supination): Affected arm on table with elbow unsupported
at side. Patient asked to supinate and pronate forearm (3/4 range acceptable).
4. Place a 5 inch ball on the table so that the patient has to reach forearm
with arm extended to reach it. Have the patient reach forward with shoulder
protracted, elbow extended, wrist in neutral or extended, pick up the ball
with both hands and put it back down in the same spot.
5. Have the patient pick up a polystyrene cup with their affected hand and
put it on the table on the other side of their body without any alteration
to the cup.
6. Continuous opposition of thumb to each finger fourteen times in 10 seconds.
Each in turn taps the thumb, starting with the index finger. Do not allow
thumb to slide from one finger to the other or go backwards.
Advanced Hand Activities

1. Have the patient reach forward to pick up the top of a pen with their
affected hand, bring the affected arm back to their side and put the pen
cap down in front of them.
2. Place eight jellybeans, (beans), in a teacup an arm’s length away on the
affected side. Place another teacup an arm’s length away on the intact side.
Have the patient pick up one jellybean with their affected hand and place
the jellybean in the cup on the intact side.
3. Draw a vertical line on a piece of paper. Have the patient draw horizontal
lines to touch the vertical line. The goal is 10 lines in 20 seconds with
at least 5 lines stopping at the vertical.
4. Have the patient pick up a pen/pencil with their affected hand, hold the
pen as for writing, and position it without assistance and make rapid
consecutive dots (not strokes) on a sheet of paper. Goal: At least 2 dots
a second for 5 seconds.
5. Have the patient take a dessert spoon of liquid to their mouth with their
affected hand without lowering the head toward the spoon or spilling.
6. Have the patient hold a comb and comb the back of their head with the
affected arm in abduction and external rotation, forearm in supination.
General Tonus (check one—add “6” to score if tone on affected side is
normal)
_____ Flaccid, limp, no resistance when body parts are handled.
_____ Some resistance felt as body parts are moved.
_____ Variable, sometimes flaccid, sometimes good tone, sometimes hypertonic.
_____ Hypertonic 50% of the time.
_____ Hypertonic all of the time.
6 = Consistently normal response
This test is designed to assess the return of function, a stroke or other neurological
impairment. The test looks at a patient’s ability to move with low tone or
in a synergic pattern and finally move actively out of that patient into normal
movement.
The higher the score, the higher the functioning; the patient is on the affected
side.
High score: 54
Low score: 0
MOTRICITY INDEX
The Motricity Index for motor Impairment after Stroke
Overview: The Motricity Index can be used to assess the motor impairment
in a patient who has a stroke.
Tests for Each Arm:
1. Pinch grip: Using a 2.5 cm cube between the thumb and forefinger
• 19 points are given if able to grip cube but not hold it against gravity
• 22 points are given if able to hold cube against gravity but not against
a week pull
• 26 points are given if able to hold the cube against a weak pull strength
is weaker than normal.
2. Elbow flexion from 90° so that the arm touches the shoulder
• 14 points are given if movement is seen with elbow out the arm horizontal.
3. Shoulder abduction moving the flexed elbow from off the chest
• 19 points are given when shoulder is abducted to more than 90° beyond
the horizontal against gravity but not against resistance.
Test for each Leg:
1. Ankle dorsiflexion with foot in a foot in a plantar flexed position
• 14 points are given if there is less than a full range of dorsiflexion.
2. Knee extension with the foot unsupported and the knee at 90°
• 14 points are given for less than 50% of full extension.
• 19 points are given for full extension.
3. Hip flexion with the hip bent at 90° moving the knee towards the chin
• 14 points are given if there is less than a full range of passive motion
• 19 points are given if the hip is fully flexed yet it can be easily pushed
down.
MRC grade MRC Points for Points for
score pinch grip other tests
No movement 0 0 0
Palpable flicker but no movement 1 11 9
Movement but not against gravity 2 19 14
Movement against gravity 3 22 19
Movement against resistance 4 26 25
Normal 5 33 33
Arm score for each side = SUM (points for the 3 arm tests) + 1
Leg score for each side = SUM (points for the 3 leg tests) + 1
Side score for each side = [(arm score for side) + (leg score for side)]/2
Interpretation:
References
1. Collin C, Wade D. Assessing motor impairment after stroke: A pilot reliability study.
J Neurology Neurosurg Psychiatry. 1990;53:576-9.
NIH STROKE SCALE

Patient identification: __ __ __ __ __ __ __
Pt. Date of birth: __ __ /__ __/__ __ __ __
Hospital: ______________(__ __-__ __)
Date of examination: __ __ /__ __/__ __ __
Interval: [ ] Baseline [ ] 2 hours post-treatment [ ] 24 hours post onset of
symptoms ± 20 minutes [ ] 7–10 days [ ] 3 months [ ] Other
_____________(__ __)
Time:__ __:__ __ [ ]am [ ]pm
Person Administering Scale_______________________________
Administer stroke scale items in the order listed. Record performance in
each category after each subscale exam. Do not go back and change score.
Follow directions provided for each exam technique. Score should reflect what
the patient does, not what the clinician thinks the patients can do. The clinician
should record answer while administering the exam and work quickly. Expect
where indicated, the patient should not be coached (i.e., repeated requests
to patient to make a special effort).
Instructions Scale definition Score

1a. Level of 0 = alert; keenly responsive. __________
consciousness 1 = Not alert; but arousable by minor
stimulation to obey, answer, or respond.
2 = Not alert; requires repeated stimulation
to attend, or is obtunded and requires
strong or painful stimulation to make
movements (not stereotyped).
3 = Responds only with reflex motor or
automatic effects or totally unresponsive,
flaccid, and are flexic.
1b. LOC 0 = Answers both questions correctly. __________

Questions: 1 = Answers one question correctly.
2 = Answers neither question correctly.
1c. LOC 0 = Performs both tasks correctly. __________
Commands 1 = Performs one task correctly.
2 = Performs neither task correctly.
2. Best Gaze 0 = Normal. __________
1 = Partial gaze palsy; gaze is abnormal
in one or both eyes, but forced
deviation or total gaze paresis is
not present.
2 = Forced deviation, or total gaze paresis
not overcome by the oculocephalic
maneuver.
3. Visual 0 = No visual loss. __________
1 = Partial hemianopia.
3 = Bilateral hemianopia
(blind including cortical blindness)
4. Facial palsy 0 = Normal symmetrical movements. __________
1 = Minor paralysis (flattened nasolabial
fold, asymmetry on smiling).
2 = Partial paralysis (total or near-total
paralysis of lower face).
3 = Complete paralysis of one or both
sides (absence of facial movements in
the upper and lower face).
5. Motor Arm 0 = No drift; limb holds 90 (or 45) __________
degrees for full 10 seconds.
1 = Drift; limb holds (or 45) degrees, but
drifts down before full 10 seconds;
does not hit bed or other support.
2 = Some effort against gravity; limb cannot
get to or maintain (if cued) 90 (or 45)
degrees, drift down to bed, but has
some effort against gravity.
3 = No effort against gravity; limb falls.
4 = No movement.
UN = Amputation or joint fusion, explain: __________
5a. Left Arm __________
5b. Right Arm __________
6. Motor Leg 0 = No drift; leg holds 30-degrees __________
position for full 5 seconds.
1 = Drift; leg falls by the end of the
5-seconds period but does not hit bed.
2 = Some effort against gravity; leg falls to bed by 5 seconds,

but has some effort against gravity.
3 = No effort against gravity; leg falls to bed immediately.
4 = No movement.
UN= Amputation or joint fusion, explain: __________
6a. Left Leg __________
6b. Right Leg __________
7. Limb Ataxia 0 = Absent. __________
1 = Present in one limb.
2 = Present in two limbs.
UN = Amputation or joint fusion, explain: __________
8. Sensory 0 = Normal; no sensory loss. __________
1 = Mild-to-moderate sensory loss;
patient feels pinprick is less sharp or
is dull on the affected side; or there is
a loss of superficial pain with pinprick,
but patient is aware of being touched.
2 = Severe to total sensory loss; patient is
not aware of being touched in the
face, arm, and leg.
9.Best 0 = No aphasia; normal. __________
Language 1 = Mild-to-moderate aphasia; some
obvious loss of fluency or facility of
comprehension, without significant
limitation on ideas expressed or
form of expression. Reduction
of speech and/or comprehension,
however, makes conversation about
provided materials difficult or
impossible. For example, in conversation
about provided materials, examiner can
identify picture or naming card content
from patient’s response.
2 = Severe aphasia; all communication is
through fragmentary expression; great
need for inference, questioning, and
guessing by the listener. Range of
information that can be exchanged is
limited; listener carries burden of
communication. Examiner cannot
identify materials provided from
patient’s response.
3 = Mute, global aphasia; no usable
speech or auditory comprehension.
10. Dysarthria 0 = Normal. __________

1 = Mild-to-moderate dysarthria; patient
slurs at least some words and, at worst,
can be understood with some difficulty.
2 = Severe dysarthria; patient’s speech is
so slurred as to be unintelligible in the
absence of or out of proportion to any
dysphasia, or is mute/anarthric.
UN= Intubated or other physical
barrier, explain: __________
11. Extinction 0 = No abnormally.
and inatten- 1 = Visual, tactile, auditory, spatial, or
tion (formerly personal inattention or extinction
neglect) to bilateral simultaneous stimulation
in one of the sensory modalities.
2 = Profound hemi-inattention or
extinction to more than one modality;
does not recognize own hand or orients
to only one side of space.
ORGOGOZO STROKE SCALE

Patient Name: ________________________________________________
Rater Name: __________________________________________________
Date: _________________________________________________________
Activity Score
Score
Consciousness
0 = Coma
5 = Stupor
10 = Drowsiness
15 = Normal _________
Verbal Communication
0 = Impossible
5 = Difficult
10 = Normal _________
Eyes and Head Shift

0 = Forced
5 = Gaze failure
10 = None
Facial Movements
0 = Paralysis
5 = Normal _________
Arm Raising
0 = Impossible
5 = Incomplete
10 = Possible _________
Hand Movements
0 = Useless
5 = Useful
10 = Skilled
15 = Normal _________
Upper Limb Tone

5 = Normal _________
Leg Raising
0 = Impossible
5 = Gravity
10 = Resistance
15 = Normal _________
Foot Dorsiflexion
0 = Foot drop
5 = Gravity
10 = Resistance or normal _________
Lower Limb Tone

5 = Normal _________
TOTAL (0–100): ________
Reference
1. Orgogozo JM, Capildeo R. Development of neurological score for clinical evaluation
of infarctions in the Sylvian territory Presse Med. 1983:12(48):3039-44.
RIVERMEAD MOBILITY INDEX

Overview: The Rivermead Mobility Index is a measure of disability related
to bodily mobility. It demonstrates the patient’s ability to move her or his
own body. It does not measure the effective use of a wheelchair or the mobility
when aided by someone else. It was developed for patients who had suffered
a head injury or stroke at the Rivermead Rehabilitation Center in Oxford,
England.
Rivermead Motor Index
No. Parameter Question
1 Turning over Do you turn over from your back to side without help?
in bed
2 Lying to sitting From lying in bed, do you get up to sit on the edge
of the bed on your own?
3 Sitting balance Do you sit on the edge of the bed without holding
on for 10 seconds?
4 Sitting to Do you stand up (from any chair) in less than 15 seconds
standing and stands there for 15 seconds (using hands and with
an aid if necessary)?
5 Standing Observe standing for 10 seconds without any aid or
unsupported support.
6 Transfer Do you manage to move from bed to chair and back
without any help?
7 Walking inside Do you walk 10 meters with an aid or furniture if
with an aid if necessary but with no standby help?
needed
8 Stairs Do you manage a flight of stairs without help?
9 Walking inside Do you walk around outside on pavements without
(even ground) help?
10 Walking inside Do you walk 10 meters inside with no caliper splint
with no aid aid or use of furniture and no standby help?
11 Picking off floor If you drop something on the floor, do you manage
to walk 5 meters pick it up and even then walk back?
12 Walking outside Do you walk over uneven ground (grass, gravel, dirt,
(uneven ground) snow, ice, etc.) without help?
13 Bathing Do you get in and out of bath or shower unsupervised
and wash self?
14 Up and down Do you manage to go up and down 4 steps with no
4 steps rail and without help but using an aid if necessary?
15 Running Do you run 10 meters without limping in 4 seconds
(a fast walk is acceptable)?
Response Points
Yes 1
No 0
Rivermead motor index = SUM (points for all 15 questions)

Interpretation:
Minimum score = 0
Maximum score = 1
The higher the score, the better the mobility.
Reference
1. Collen FM, Wade DT, et al. The Rivermead mobility index: A further development
of the Rivermead motor assessment. Int Disabil Studies. 1991;13:50-54.
SCANDINAVIAN STROKE SCALE

Patient Name: _____________________________
Rater Name: _____________________________
Date: _____________________________
Function
Score Prognostic Long-term
score score
Consciousness:
Fully conscious 6 ______
Somnolent, can be walked to full
consciousness 4
Reacts to verbal commands, but is
not fully conscious 2
Eye movement:
No gaze palsy 4 _______
Gaze palsy present 2
Conjugate eye deviation 0
Arm, motor power*:
Raises arm with normal strength 6
Raises arm with reduced strength 5 _______
Raises arm with flexion in elbow 4
Can move, but not against gravity 2
Paralysis 0
Hand, motor power*:
Normal strength 6 _______
Reduced strength in full range 4
Some movements, fingertips do not
reach palm 2
Paralysis 0
Leg motor power*:
Normal strength 6 _______
Raises straight leg with reduced strength 5
Raises leg with flexion of knee 4
Can move, but not against gravity 2
Paralysis 0
Orientation:
Correct for time, place and person 6 _______
Two of these 4
One of these 2
Completely disoriented 0
Speech:
No aphasia 10 _______
Limited vocabulary or incoherent speech 6
More than yes/no, but no longer sentences 3
Only yes/no or less 0
Facial palsy:
None/dubious 2 _______
Present 0
Gait
Walks 5 m without aids 12 _______
Walks with aids 9
Walks with help of another person 6
Sits without support 3
Bedridden/wheelchair 0
Maximal Score ______ 22 48
* Motor power is assessed only on the affected side.
Reference
1. Multicenter trial of hemodilution is ischemic stroke—background and study protocol.
Scandinavian Stroke Study Group. Stroke. 1985;16(5):885-90.
TINETTI BALANCE ASSESSMENT TOOL

Patient’s Name: __________________ DOB: __________ Ward: _____
Balance Section
Patient is seated in hard, armless chair;
Sitting balance Leans or slides in chair = 0
Steady, safe = 1
Rises from chair Unable to, without help = 0
Able, uses arms to help = 1
Able, without use of arms = 2
Attempts to rise Unable to without help = 0
Able, requires >1 attempt = 1
Able, to rise, 1 attempt = 2
Immediate Unsteady (strangers,
standing balance moves feet, trunk sway) = 0
(first 5 seconds) Steady but uses walker or
other support = 1
Steady without walker or
other support = 2
Standing balance Unsteady = 0
Steady but wide stance
and uses support = 1
Narrow stance without support = 2
Nudged Begins to fall = 0
Staggers, grabs, catches self = 1
Steady = 2
Eyes closed Unsteady = 0
Steady = 1
Turning Discontinuous steps = 0
360 degrees Continuous = 1
Unsteady (grabs, staggery) = 0
Steady = 1
Sitting down Unsafe (misjudged distance,
falls into chair) = 0
Uses arms or not a
smooth motion = 1
Safe, smooth motion = 2
Balance score /16 /16
Gait Section
Patients stands with therapist, walks across room (+/–aids), first at usual pace,
then at rapid pace.
Indication of gait Any hesitancy or multiple = 0
(immediately after attempts
told to ‘go’.) No hesitancy = 1
Step length and Step to = 0
height Step through R = 1
Step through L = 1
Foot clearance Foot drop = 0
L foot clears floor = 1
R foot clears floor = 1
Step symmetry Right and left step length
not equal = 0
Right and left step length
appear equal = 1
Step continuity Stopping or discontinuing
between steps = 0
Steps appear continuous = 1
Path Marked deviation = 0
Mild/moderate deviation or
uses walking aid = 1
Straight without walking aid = 2
Trunk Marked sway or uses walking aid = 0
No sway but flex knees or
back or uses arms for stability = 1
No sway, flex, use of arms
or walking aid = 2
Walking time Heels apart = 0
Heels almost touching while
walking = 1
Gait score /12 /12

Balanced score carried forward /16 /16
Total score = Balance score + Gait score /28 /28
Risk Indicators:
Tinetti Tool Score Risk of falls
18 High
19–23 Moderate
24 Low
THE TRUNK CONTROL TEST FOR MOTOR

IMPAIRMENT AFTER STROKE
Overview
The trunk control test can be used to assess the motor impairment in a patient
who has had a stroke. It correlates with eventually walking ability.
Testing done by patient lying on bed

1. Roll to weak side
2. Roll to strong side
3. Balance in sitting position on the edge of the bed with the feet off the
ground for at least 30 seconds
4. Sit up from lying down
Scoring each test Points
Unable to do without assistance 0
Able to do so using nonmuscular help or in an abnormal style 12
Able to complete task normally 25
Trunk control test = SUM (points for all 4 tests)
Interpretation
 If the test is done at 6 weeks after stroke, a score more than 50 predicts
recovery of the ability to walk by 18 weeks.
Reference
1. Tinetti ME, Williams TF, Mayewski R. Fall risk index for elderly patients based
on number of chronic disabilities. Am J Med. 1986:80:429-34
2. Collin C, Wade D. Assessing motor impairment after stroke: A pilot reliability study.
J Neurol. Neurosurg Psychiatry. 1990;53:576-9.
STROKE IMPACT SCALE

The purpose of this questionnaire is to evaluate how stroke has impacted
your health and life. We want to know from Your point of view how stroke
has affected you. We will ask you questions about impairments and disabilities
caused by your stroke, as well as how stroke has affected your quality of
life. Finally, we will ask you to rate how much you think you have recovered
from your stroke:
These questions are about the physical problems that may have occurred
as a result of your stroke:
1. In the past week, how A lot Quite a Some A little No
would you rate the strength of bit of strength strength strength
of you....... strength strength at all
a. Arm that was most affected
by your stroke? 5 4 3 2 1
b. Grip of your hand that was
most affected by your stroke? 5 4 3 2 1
c. Leg that was most affected
by your stroke? 5 4 3 2 1
d. Foot/ankle that was most
affected by your stroke? 5 4 3 2 1
These questions are about your memory and thinking:

2. In the past week, how Not A little Somewhat Very Extremely
difficult was it to ..... difficult difficult difficult difficult difficult
at all
a. Remember things that
people just told you? 5 4 3 2 1
b. Remember things that
happened yesterday? 5 4 3 2 1
c. Remember to do things
(e.g., keep scheduled appoint-
ments or take medication)? 5 4 3 2 1
d. Remember the day of the
week? 5 4 3 2 1
e. Add and subtract numbers? 5 4 3 2 1
f. Concentrate? 5 4 3 2 1
g. Think quickly? 5 4 3 2 1
h. Solve problems? 5 4 3 2 1
These questions are about how you feel, about changes in your mood and
about your ability to control your emotions since your stroke.
3. In the past week, how None A little Some Most All of
often did you ...... of the of the of the of the the
time time time time time
a. Feel sad? 5 4 3 2 1
b. Feel that there is nobody
you are close to? 5 4 3 2 1
c. Feel that you are a burden
to others? 5 4 3 2 1
d. Feel that you have nothing
to look forward to? 5 4 3 2 1
e. Blame yourself for mistakes? 5 4 3 2 1
f. Enjoy things as much as
you ever have? 5 4 3 2 1
g. Feel quite nervous? 5 4 3 2 1
h. Feel that life is worth living? 5 4 3 2 1
i. Smile and laugh at least once
a day? 5 4 3 2 1
The following items are about your ability to communicate with other people,
as well as your ability to understand what you read and what you hear in
a conversation:
4. In the past, how difficult Not A little Somewhat Very Extremely
was it to ..... difficult difficult difficult difficult difficult
at all
a. Say the name of someone
whose face was in front
of you? 5 4 3 2 1
b. Understand what was being
said to you in a conversation? 5 4 3 2 1
c. Reply to questions? 5 4 3 2 1
d. Correctly name objects? 5 4 3 1
e. Participate in a conversation
with a group of people? 5 4 3 2 1
f. Have a conversation on the
telephone? 5 4 3 2 1
g. Call another person on the
telephone (select the correct
phone number and dial)? 5 4 3 2 1
The following items ask about activities you might do during a typical day:
5. In the past two weeks, Not A little Somewhat Very Cannot
how difficult was it to ...... difficult difficult difficult difficult do at
at all all
a. Cut your food with a
knife and fork? 5 4 3 2 1
b. Dress the top part (waist up)
of your body? 5 4 3 2 1
c. Bathe yourself? 5 4 3 2 1
d. Clip your toenails? 5 4 3 2 1
e. Get to the toilet on time? 5 4 3 2 1
f. Control your bladder
(not have an accident)? 5 4 3 2 1
g. Control your bowels
(not have an accident)? 5 4 3 2 1
h. Do light household task/chores
(e.g. dust, make a bed, take out
garbage, do the dishes)? 5 4 3 2 1
i. Go shopping? 5 4 3 2 1
j. Handle money (e.g. pay
monthly bills, manage
checking account)? 5 4 3 2 1
k. Do heavy household chores
(e.g. vacuum, laundry or
yard work)? 5 4 3 2 1
The following questions are about your ability to be mobile, at home and
in the community:
6. In the past 2 weeks, Not A little Somewhat Very Cannot
how difficult was it to ...... difficulty difficulty difficult difficult do at
at all all
a. Sit without losing your balance? 5 4 3 2 1
b. Stand without losing your
balance? 5 4 3 2 1
c. Walk without losing your
balance? 5 4 3 2 1
d. Move from a bed to a chair? 5 4 3 2 1
e. Get out of a chair without
using your hands for support? 5 4 3 2 1
f. Walk one block? 5 4 3 2 1
g. Walk fast? 5 4 3 2 1
h. Climb one flight of stairs? 5 4 3 2 1
i. Climb several flights of stairs? 5 4 3 2 1
j. Get in and out of a car? 5 4 3 2 1
The following questions are about your ability to use your hand that was
most affected by your stroke.
7. In the past 2 weeks, Not A little Somewhat Very Cannot
how difficult was it to difficulty difficulty difficult difficult do at
use your hand that at all all
was most affected
by your stroke to ......
a. Carry heavy objects
(e.g. bag of groceries)? 5 4 3 2 1
b. Turn a doorknob? 5 4 3 2 1
c. Open a can or jar? 5 4 3 2 1
d. Tie a shoelace? 5 4 3 2 1
e. Pick up a dime? 5 4 3 2 1
The following questions are about how stroke has affected your ability to
participate in the activities that you usually do, things that are meaningful
to you and help you to find purpose in life:
8. During the past 4 weeks, None A little Some Most All of
how much of the time of the of the of the of the the
have you been limited time time time time time
in ......
a. Your work, volunteer or
other activities? 5 4 3 2 11
b. Your social activities? 5 4 3 2 1
c. Quite recreation (crafts, reading)? 5 4 3 2 1
d. Active reaction
(sports, outings, travel)? 5 4 3 2 1
e. Your role as a family member
and/or friend? 5 4 3 2 1
f. Your participation in spiritual
or religious activities? 5 4 3 2 1
g. Your ability to feel emotionally
connected to another person? 5 4 3 2 1
h. Your ability to control
your life as you wish? 5 4 3 2 1
i. Your ability to help others
in need? 5 4 3 2 1
On a scale of 0 to 100 representing full recovery and 0 representing no recovery,

how much have you recovered from your stroke?
|_____|_____|_____|_____|_____|_____|_____|_____|_____|_____|_____|
0 10 20 30 40 50 60 70 80 90 100
(Experienced (Fully
no recovery) recovered)
FUNCTIONAL INDEPENDENCE MEASURE (FIM)

Category Measure
Self-care Feeding
Grooming
Bathing
Dressing upper body
Dressing lower body
Toileting
Sphincter Control Bladder
Bowel
Transfers Bed, chair, wheelchair
Mobility Toilet
Tub or shower
Locomotion Walker or wheelchair
Stairs
Communication and Cognition Comprehension
Expression
Social interaction
Problem solving
Memory
Total 18 measures
For each measure Score
Complete independence, unaided 7
Modified independence, with device 6
Can perform with supervision 5
Able to complete 75% of activity;
needs minimal assistance 4
needs moderate assistance 3
needs significant assistance 2
Unable to complete limited activity;
requires total assistance 1
FIM score = Summation of score for each measure

Interpretation:
• Maximum FIM score = 18 * 7 = 126
• The higher the FIM score, the better the patient outcomes.
BERG BALANCE
Patient Name: _______________________________

Rater Name: _________________________________
Date: _______________________________________
Balance Item Score (0–4)
1. Sitting unsupported _________

2. Change of position: Sitting to standing _________
3. Change of position: Standing to sitting _________
4. Transfers _________
5. Standing unsupported _________
6. Standing with eyes closed _________
7. Standing with feet together _________
8. Tandem standing _________
9. Standing on one leg _________
10. Turning trunk (feet fixed) _________
11. Retrieving objects from floor _________
12. Turning 360 degrees _________
13. Stool stepping _________
14. Reaching forward while standing _________
TOTAL (0–56): _________
Interpretation
0–20: Wheelchair bound
21–40: Walking with assistance
41–56: Independent
THE REHABILITATION INDEX

Overview: The rehabilitation index is a measure of the resources that a person
has to aid in his or her response to injury and to be rehabilitated as much
as possible.
Factors measured:
1. Impairment from injury
2. Chronicity
3. Expected response
4. Intelligence quotient
5. Past performance in work and school
6. Emotional stability (poor to good)
7. Personality (poor to good)
8. Influence of socioeconomic status (bad to good)
9. Influence of other physical defects (marked to none)
10. Motivation.
Scoring:
• Points assigned from 1 to 10
• The higher the score, the better the resource (1 = worst; 10 = best)
Rehabilitation index = SUM (points for all 10 factors)
Interpretation:
• Minimum score: 10
• Maximum score: 100
• An index < = 48 indicates that the patient is at poor risk for rehabilitation.
Limitations:
• All factors are graded equally but factors such as intelligence emotional
stability and motivation can help some patients overcome adversity despite
poor scores in other areas.
Bibliography 493
Bibliography
1. Actherberg S, Kappelle L, Algra A. Prognostic Modelling in Ischaemic Stroke Study,

Additional Value of Genetic Characteristics Rationale and Design. Eur Neurol.
2008);59(5):243-52.
2. Allison R, Dennett R. Pilot randomized controlled trial to assess the impact of additional
supported standing practice on functional ability post stroke. Clin Rehabil. 2007;
21(7):614-9.
3. Brahmachari I. Rehabilitation of stroke patients in Indian scenario: Activity and
participation perspective. Ind J Phys Ther. 2013;1(2):47-51.
4. Bolpe B, Lynch D, Berland A. Intensive Sensorimotor Arm Training Mediated by
Therapist or Robot Improves Hemiparesis in Patients with Chronic Stroke. Neurorehabil
Neural Repair. 2008;22(3):305-10.
5. Brogardh C, Sjoulund B. Constraint-induced movement therapy in patients with stroke:
A pilot study on effects of small group training and of extended mitt use. Clin
Rehabil. 2006;20(3):218-27.
6. Burnhardt J, Chitravas N, Meslo I. Not All Stroke Units are the Same: A Comparison
of Physical Activity Patterns in Melbourne, Australia, and Trondheim, Norway. Stroke.
2008;39:2059-65.
7. Burns A, Burridge J, Pickering R. Does the use of a constraint mitten to encourage
use of the hemiplegic upper limb improve arm function in adults with subacute
stroke? Clin Rehabil. 2007;20(10):895-904.
8. Byl N, Roderick J, Mohamed O. Effectiveness of Sensory and Motor Rehabilitation
of the Upper Limb Following the Principles of Neuroplasticity: Patients Stable
Poststroke. Neurorehabil Neural Repair. 2003;17(3):171-6.
9. Canning C, Ada L, Adams R. Loss of strength contributes more to physical disability
after stroke than loss of dexterity. Clin Rehabil. 2004;18(3):300-08.
10. Casadio M. A proof of concept study for the integration of robot therapy with physiotherapy
in the treatment of stroke patients. Clin Rehabil. 2003;23(3): 217-28.
11. Chae J, Hart R. Intramuscular Hand Neuroprosthesis for Chronic Stroke Survivors.
Neurorehabil Neural Repair. 2003;17(2):109-17.
12. Chae J, Ng A, Yu D. Intramuscular Electrical Stimulation for Shoulder Pain in
Hemiplegia: Does Time From Stroke Onset Predict Treatment Success? Neurorehabil
Neural Repair. 2007;21(6):561-7.
13. Chan J, Liang C, Shaw F. Facilitation of Sensory and Motor Recovery by Thermal
Intervention for the Hemiplegic Upper Limb in Acute Stroke Patients. Stroke.
2005;36(255):2665.
14. Church C, Price C, Pandyan A. Randomized Controlled Trial to Evaluate the Effect
of Surface Neuromuscular Electrical Stimulation to the Shoulder after Acute Stroke.
Stroke. 2006;37:2995-3001.
15. Dong K, Lim J, Shin H. The effect of aquatic therapy on postural balance and
muscle strength in stroke survivors — a randomized controlled pilot trial. Clin Rehabil.
2008;22(10-11):966-76.
16. Duncan P, Zorowitz R, Dates B. Management of adult stroke rehabilitation care.
Stroke. 2005;36:e100-e143.
17. Fang Y, Chen X, Li H. A study on additional early physiotherapy after stroke and
factors affecting functional recovery. Clin Rehabil. 2003;17(6):608-17.
18. Feys H, Weerdt W, Verbeke G. Early and Repetitive Stimulation of the Arm can
Substantially Improve the Long-term Outcome after Stroke: A 5-year Follow-up Study
of a Randomized Trial. Stroke 2004;35:924-9.
19. Giaquinto S, Spiridigliozzi C. Religious faith eases post-stroke distress, may aid
recovery: American heart Association, 2007.
20. Goodwin N, Sunderland A. Intensive, time-series measurement of upper limb recovery
in the subacute phase following stroke. Clin Rehabil. 2003;17(1):69-82.
21. Green J, Young J, Forster A. Combined analysis of two randomized trials of community
physiotherapy for patients more than one year post stroke. Clin Rehabil. 2004;18(3):
249-52.
22. Han SW, Kim SH, Lee JY. A New Subtype Classification of Ischemic Stroke Based
on Treatment and Etiologic Mechanism. Eur Neurol. 2007;57(2).
23. Harris J, Eng J. Individuals with the Dominant Hand Affected following Stroke
Demonstrate Less Impairment than Those with the Nondominant Hand Affected.
24. Hesse S, Werner C, Pohl M. Computerized Arm Training Improves the Motor Control
of the Severely Affected Arm after Stroke. Stroke. 2005;36:1960.
25. Higgins J, Salbach N, Wood S. The effect of a task-oriented intervention on arm
function in people with stroke: A randomized controlled trial. Clin Rehabil.
2006;20(4):296-310.
26. Howe T, Taylor Y, Finn P. Lateral weight transference exercises following acute stroke:
A preliminary study of clinical effectiveness. Clin Rehabil. 2005;19(1):45-53.
27. Jehkonen M, Laihosalo M, Koivisto A. Fluctuation in Spontaneous Recovery of Left
Visual Neglect: A 1-year Follow-up. Eur Neurol. 2007;58:210-14.
28. Juha K, Neiminen P, Myllyla V. Sexual Functioning Among Stroke Patients and
Their Spouses. Stroke. 1999;30:715-9.
29. Kalra L, Perez I, Gupta S. The Influence of Visual Neglect on Stroke Rehabilitation.
Stroke. 1997;28:1386-91.
30. Kalra L, Ratan R. Advances in Stroke Regenerative Medicine. Stroke. 2007;39:273-5.
31. Kalra. Faith Under the Microscope. Stroke. 2007;38:848.
32. Kjendahl A. A one year follow-up study on the effects of acupuncture in the treatment
of stroke patients in the subacute stage: A randomized, controlled study. Clin Rehabil.
1997;11(3):192-200.
33. Kroon J, Ijzerman M. Electrical stimulation of the upper extremity in stroke: Cyclic
versus EMG-triggered stimulation. Clin Rehabil. 2008;22(8):690-7.
34. Kwakel G, Peppen R, Waggener R. Effects of Augmented Exercise Therapy Time
after Stroke. Stroke. 2004;35(25):2529-39 .
Bibliography 495
35. Kwakel G, Waggener R, Koelman T. Effects of Intensity of Rehabilitation after Stroke:

A Research Synthesis. Stroke. 1997;28:1550-6.
36. Lackner E, Hummelshein H. Motor-evoked potentials are facilitated during perceptual
identification of hand position in healthy subjects and stroke patients. Clin Rehabil.
2003;17(6):648-55.
37. Lamina S, Hanif S, Darnley I. Effect of Cerebrovascular Accident on Sexual Function
of Male Hemiplegic Patients. J Med Rehabil. 2007;1(1).
38. Langhorne P, Wagennar R, Partridge C. Physiotherapy after stroke: More is better?
Physiotherapy Res Int. 1996;1(2):75-88.
39. Lettinga A, Reynders A, Mulder T. Pitfalls in effectiveness research: A comparative
analysis of treatment goals and outcome measures in stroke rehabilitation. Clin Rehabil.
2002;16(2):174-81.
40. Leung J, Moseley A, Fereday S. The prevalence and characteristics of shoulder pain
after traumatic brain injury. Clin Rehabil. 2007;21(2):171-81.
41. Lincoln N, Parry R, Vas C. Randomized, Controlled Trial to Evaluate Increased Intensity
of Physiotherapy Treatment of Arm Function after Stroke. Stroke. 1999;30:573-9.
42. Luke C, Dod K, Brock K. Outcomes of the Bobath concept on upper limb recovery
following stroke. Clin Rehabil. 2004;18(8): 888-98.
43. Margaret R, Turner S. Effectiveness of brain injury rehabilitation. Clin Rehabil.
1999;13(1):7-24.
44. Merians A, Jack D, Tremaine M. Virtual Reality–Augmented Rehabilitation for Patients
Following Stroke. Phys Ther. 2002;82(9):898-915.
45. Ozcakir S, Siviroghu K. Botulinium toxin in post stroke spasticity, clinical medicine
and research. 2007;5(2):132-8.
46. Page S, Levine P, Sisto S. Mental Practice Combined With Physical Practice for Upper
Limb Motor Deficit in Subacute Stroke. Phys Ther 2001;81(8):1455-62.
47. Parry R, Lincoln N, Vass C. Effect of severity of arm impairment on response to
additional physiotherapy early after stroke. Clin Rehabil. 1999;13(3):187-98.
48. Platz T, Eickhof C, Kaick S. Impairment-oriented training or Bobath therapy for
severe arm paresis after stroke: A single-blind, multicentre randomized controlled
trial. Clin rehabil. 2005;19(7):714-24.
49. Pohl M, Werner C, Holzgraefe M. Repetitive locomotor training and physiotherapy
improve walking and basic activities of daily living after stroke: A single-blind,
randomized multicentre trial. Clin Rehabil. 2007;21(1):17-27.
50. Pollock A, Baer G, Pomeroy P. Physiotherapy treatment approaches for the recovery
of postural control and lower limb function following stroke. Cochrane Database
Syst Rev 1 (2007) , CD 001920.
51. Rodgers H, Mackintosh J, Price C. Does an early increased-intensity interdisciplinary
upper limb therapy programme following acute stroke improve outcome? Clin Rehabil.
2003;17(6):579-89.
52. Rosales R, Kong K, Goh K. Botulinium toxin injection for hypertonicity of upper extremity
within 12 weeks after stroke. Neurorehab Neural Repair. 2012;26(7):812-21.
53. Ryan T, Enderby P, Rigby A. A randomized controlled trial to evaluate intensity
of community-based rehabilitation provision following stroke or hip fracture in old
age. Clin Rehabil. 2006;20(2):123-31.
54. Sacco S, Toni T, Angelo A. Acute Stroke Admission and Diagnostic Procedures
According to the Hour and Day of Onset. Eur Neurol. 2009;61(2):100-06.
55. Seelen H, Hemmen B. Effects of movement imagery and electromyography-triggered
feedback on arm-hand function in stroke patients in the subacute phase. Clin Rehabil.
2007;21(7):587-94.
56. Sheffler L, Hennessey M, Naples G. Improvement in Functional Ambulation as a

Therapeutic Effect of Peroneal Nerve Stimulation in Hemiplegia: Two Case Reports.
57. Stinear J, Byblow W. Rhythmic bilateral movement training modulates corticomotor
excitability and enhances upper limb motricity poststroke: A pilot study. J Clin
Neurophysiol. 2004;21(2):124-31.
58. Sullivan JE, and Hedman LD. A Home Program of Sensory and Neuromuscular
Electrical Stimulation with Upper-limb Task Practice in a Patient 5 Years after a
Stroke. Phys Ther. November 2004;84 (11):1045-54.
59. Ter zoudi A, Vorvolakos T, Heliopoulos I. Sleep Architecture in Stroke and Relation
to Outcome. Eur Neurol. 2009;61(1).
60. The Glasgow Augmented Physiotherapy Study (GAPS) group. Can augmented
physiotherapy input enhance recovery of mobility after stroke? A randomized controlled
trial. Clin Rehabil. 2004;18(5):529-37.
61. Turton AJ. A multiple case design experiment to investigate the performance and
neural effects of a programme for training hand function after stroke. Clin Rehabil.
2004;18(7):754-63.
62. Van der Lee J, Snels I, Beckerman H. Exercise therapy for arm function in stroke
patients: A systematic review of randomized controlled trials. Clin Rehabil.
2001;15(1):20-31.
63. Varona J, Guerra J, Bermajo F. Causes of Ischemic Stroke in Young Adults, and Evolution
of the Etiological Diagnosis over the Long Term. Clin Neurol. 2007;57(4):212-8.
64. Verheyden G, Nieuwboer A, Winckel A. Clinical tools to measure trunk performance
after stroke: A systematic review of the literature. Clin Rehabil. 2007:21(5):387-94.
65. Vliet P, Lincoln N, Foxall A. Comparison of Bobath based and movement science
based treatment for stroke: A randomised controlled trial. J Neurol Neurosurg Psychiatry.
2005;76:503-08.
66. Volpe B, Krebs H, Hogan N. Robot training enhanced motor outcome in patients
with stroke maintained over 3 years. Neurology. 1999;53:1874.
67. Volpe BT, Krebs HI, Hogan N. A novel approach to stroke rehabilitation: Robot-
aided sensorimotor stimulation. Neurol. 2000;54:1938-44.
68. Wade D, Collen F, Robb G. Physiotherapy intervention late after stroke and mobility.
BMJ. 1992;304:6827.
69. WHO Infobase Ref. #: S00753a1.
70. Wiles R, Ashburn A, Payne S. Discharge from physiotherapy following stroke: The
management of disappointment. Soc Sci Med. September 2004;59(6):1263-73.
71. Winckel A, Feys H, Lincoln N. Assessment of arm function in stroke patients: Rivermead
Motor Assessment arm section revised with Rasch analysis. Clin Rehabil.
2007;21(5):471-5.
72. Woldag H, Waldmann G, Heuschkel G. Is the repetitive training of complex hand
and arm movements beneficial for motor recovery in stroke patients? Clin Rehabil.
2003;17(7):723-30.
73. Yozbatian N, Donmez B, Kayak N. Electrical stimulation of wrist and fingers for
sensory and functional recovery in acute hemiplegia. Clin Rehabil. 2006;20(1):4-11.
Bibliography 497
RECOMMENDED BOOKS FOR FURTHER

READING
1. The Principles of Exercise Therapy by M. Dena Gardiner, CBS Publishers & Distributors
Pvt Ltd, 2005.
2. Adult Hemiplegia Evaluation and Treatment by Berta Bobath, 1990.
3. Steps to Follow: The Comprehensive Treatment of Patients with Hemiplegia by Patricia
M. Davies, Springer, 2000.
4. Right in the Middle: Selective Trunk Activity in the Treatment of Adult Hemiplegia
by Patricia M. Davies, Springer, 1990.
5. Cash’s Textbook of Neurology for Physiotherapists by Patricia A. Downie, Jaypee
Brothers Medical Publishers (P) Ltd, 1993.
6. Practical Exercise Therapy, Margaret Hollis, Phyllis Fletcher Cook (Ed), Wiley–
Blackwell, 1999.
7. Physical Rehabilitation by Susan B. O’Sullivan and Thomas J. Schmitz, F. Davis
Company, 2014.
8. Tidy’s Physiotherapy, Stuart Porter, Churchill Livingstone, 2013.
9. Treatment for Hemiplegia by Sarah Johnstone.
10. PNF in Practice: An Illustrated Guide by Susan Adler, Springer, 2007.
11. A Motor Relearning Programme for Stroke by Janet H. Carr and Roberta B. Shepherd,
Aspen Publishers, 1987.
12. Clayton’s Electrotherapy (Physiotherapy Essentials) by Sheila Kitchen and Sarah Bazin,
Bailliere Tindall, 1995.
13. BD Chaurasia’s Human Anatomy by BD Chaurasia, CBS Publishers, 2013.
14. Guyton and Hall Textbook of Medical Physiology by John E. Hall, Elsevier Health
Science, 2013.
15. Harrison’s Principles of Internal Medicine by Dan Longo, Anthony Fauci, Dennis
Kasper, Stephen Hauser, J Jameson, Joseph Loscalzo, McGraw-Hill, 2011.
Index 499
Index
Page numbers followed by t refer to table, f refer to figure and b refer to box.
A Aortic dissection 44
ABCD score 434 Aphasia 50, 53t, 68, 330, 343, 344
Abdominal activation 181f, 182f central 54t
Abdominal muscles 165 fluent 68
Abnormal gait pattern 271 global 68, 474
factors responsible mild-to-moderate 474
adaptive patterns 272 motor 54t
primary neurogenic 271 nonfluent 68
Abulia 55t severe 474
Acalculia 54t, 334 tactile 55t
Active adduction-extension, of fingers 222f Apractognosia 54t
Adductor pollicis (AP) 410 Apraxia 67, 80, 339, 343, 344, 345
AFO 371, 373 assessment 346
dynamic 372 constructional 54t, 335, 347, 348, 349
merits 374 assessment 348
Agnosia 80, 342 treatment 349
auditory 343 dressing 54t, 335
assessment 343 assessment 349
treatment 343 treatment 350
color 342 gait 55t
olfactory 344 ideational 67, 346
visual object 342 ideomotor 67, 345
assessment 343 treatment 346
treatment 343 Arachnoid mater 3
Agraphia 54t, 334 Arachnoid villi 4, 4f
Air stirrup ankle brace 371 Arm
AKBK (above knee below knee) splint 279f, elevation of 167
279 mobilizing 166
Alien arm syndrome 50, 51 Arterial hypertension 8
Alien hand syndrome 327 Arteries
Anencephaly 21 basilar 7f, 30
Aneurysm 99 carotid 43
Aneurysm, leaking 37 cerebral
Ankle evertors 63 anterior 7f
Anosognosia 54t, 69, 145, 327, 329, 334 middle 7f, 30, 35
Antispastic agents posterior 35
baclofen 400 communicating
clonidine 400 anterior 7f, 7
diazepam 400 posterior 7f, 7
extracranial 33 sphenoid 3
internal carotid 7f temporal 3
retinal 33 Bradykinesia 128, 129
vertebral 7f, 30 Brain damage
occlusion of 57t signs and symptoms 54
Arteriovenous malformations (AVMs) 31 structures involved 54
Asomatognosia 327 Brain
Astereognosis 53t, 326, 327 areas of 12f
Ataxia 59t blood supply to 7
of limbs 59t lesion sites
Atheroma 30 basis pontis 53t
Atherosclerosis 35 brainstem syndrome 53t
Atrial fibrillation 31, 36, 47 cerebral cortex 53t
Autoimmune angiitis 38 cerebral peduncle 53t
Ayres figure ground test 336 cerebral white 53t
internal capsule 53t
B low pontine lesions 53t
medullary pyramids 53t
Barbiturates 99
neonatal 9
Barthel ADL index, guidelines 436
pneumoencephalography 46
Barthel index 82, 380, 435
ventriculography 46
Basal ganglia 6, 51, 66
Brainstem 4, 5, 5f, 6
associated signs and symptoms 16t
Bridging 184
functions 16t
unilateral
Basilar artery syndrome 57t dynamic activities 185f
Beck’s depression inventory 437, 439 resistance 185f
Bedsores 148 thoracic stability 185f
Berg balance 440, 490 weight bearing on hemiplegic side
Biceps branchii tendon 174f 184f
Bicycle ergometry 366f weight bearing on sound side 184f
Bilateral symmetrical pattern with both upper limbs held in flexion 184f
in supine—flexion—abduction 309 Broca’s area 12f
of activities 228 Brunnstrom classification
Binswanger’s disease 36 for recovery of stroke
Bladder and bowel dysfunction 71 stage 1 60
Bobath assessment 81, 82 stage 2 60
Bobath assessment form 86 stage 3 60
Bobath classification 61 stage 4 60
Bobath sling 150, 151 stage 5 61
Bones stage 6 61
clavicle 174f Brunnstrom form 82
cranial 2 Brunnstrom test 81
ethmoid 3 Brush and sweep tapping 116
facial 2 Brushing 155
frontal 2 BTX 35, 402
humerus 174f benefits 380
occipital 2 effects 380
of skull 3f evaluation 376
parietal 2 order for 378
scapula 174f Butler techniques 356
Index 501
C Contractions
Calcium channel blockers 99 concentric 130
Calf muscles 272 eccentric 130
Canadian neurological scale 441 isometric 130
Cardiac arrhythmias 47 Contracture evaluation 398
Carotid bruit 35 Contralateral grasp reflex 55t
asymptomatic 38 Coracoacromial ligament 174f
Carpal tunnel syndrome 357 Coracoid process 174f
Central speech area 54t Corpus callosum
Cerebellum 4, 5, 5f, 6, 7, 12f, 51 associated signs and symptoms 15t
Cerebral aqueduct 6 functions 15t
Cerebral blood flow (CBF) 8 Cortical blindness 40
Cerebral cortex, functions 13t Crossed hand technique 159f
Cerebral diplegia 252f benefits 159
Cerebral hemispheres 4, 5f, 30 Cutaneous reflexes 63
Cerebral infarction
D
acute, medical management of 98
embolic 31 Deconditioning 75
lacunar 31 Deep venous thrombosis 73, 148
thrombotic 31 Deglutition, grip for facilitation 323f
Cerebral perfusion 99 Dentothalamic tract 56t
Cerebral perfusion pressure (CPP) 8 Depression, post-stroke 73
Cerebrospinal fluid 3, 4 Depth perception 340
Cerebrospinal fluid tests 47 Diabetes mellitus 35, 75, 98
Cerebrovascular accident 30 Diencephalon 4, 5, 5f, 6, 9
Cerebrovascular disease, risk factors for 34 Diplopia 59t
Chest physiotherapy Disability 102, 103
abdominal breathing and activation of Distance perception 340
diaphragm 141 assessment 340
segmental breathing exercises 141 Dizziness 42
vibrations and percussions 141 Dura mater 3
Chewing, grip for facilitation of 323f Dural venous sinuses 4
Choreoathetosis 56t Dynamic balance reactions 212
Choroid plexuses 4, 4f, 6 Dysarthria 50, 68, 314
Cincinnati prehospital stroke scale 442 Dysesthesias 56t
Circle of Willis 7, 7f Dysphagia 50, 68, 71
Clasp-knife reflex 63 Dyspraxia 55t
Claude’s syndrome 56t Dystonia 66
Clostridium botulinum 402
CNS disorders 49 E
Cognition and communication evaluation 398 Efferent impulses 113
Cognitive dysfunction Elastic band
assessment 350 elbow flexion and extension 225
attention 350 shoulder external rotation 225
cognition 350 Elbow flexion 223
memory 350 Elbow flexors 62
orientation 350 Emboli 30
Computer-aided therapy 367 EMG triggered electrical stimulation 364
Connective tissue release 156 Emotional dysfunction 351
Constraint therapy, limitations 368 Encephalitis 46
Encephalopathy 39 Gait training 274

Endocarditis, bacterial 33 advanced 277
Epithalamus 6 orthosis in 274
Equinus gait 83t resisted 277f
European stroke scale 443 Geriatric depression scale 454
Exercise conditioning 366 Gerstmann’s syndrome 54t, 328t, 334
Extensor thrust 206 Giant aneurysm 35
Eye movements, coordination of activities for Glasgow coma scale 455
323 Glenohumeral joint 148
subluxation 164
F Glumate receptors blockers 99
Facial palsy 53t, 473 Gluteal walking 203, 217f
Facilitation 113 Goodglass and Kaplan test 346
Fainting 42 Granulomatous arteritis 35
Family assessment device 447 Gray matter 5
Femur 267 motor areas 5
Fibromuscular dysplasia 36 sensory areas 5
Figure ground discrimination 335 Gross motor development 125t
treatment 336 Guyon’s canal 411
Finger agnosia 327, 329, 334
treatment 334 H
Finger extensors 63 Hammer toes 83t
Finger-to-finger touching 247f Handicap 102, 103
Flaccidity 60 Head, anatomy of 1
Flexor pollicis brevis 410 Headache 42
Fluid-attenuated inversion recovery 47 Heart disease 98
Foot movements 241 Heel strike 276
Foramen magnum 3 Hematoma
Forearm pronators 62 intracerebral 34
Forearm supination 223 subdural 99
Forearm supination and pronation training Hemianopia 51
228 bilateral 473
Form consistency contralateral homonymous 30
assessment 337 homonymous 55t, 330
treatment 337 partial 473
Frenchay activities index 453 Hemianopsia 331
Fugl–Meyer assessment (FMA) 81 left-sided 342
Functional electrical stimulation (FES) 363, Hemiasomatognosia 54t
365 Hemiballismus, acute 39
posterior deltoid 363 Hemiparesis, spastic 65
supraspinatus muscle 363 Hemiplegia 56t
Functional independence measure (FIM) 489 allied therapies 382
Functional mobility training 253 ataxic 53t
Functional walking 295 complications
bedsores 361
G deep venous thrombosis 361
Gait analysis format 83t fractures 358
Gait cycle, various activities 275 limb deformity 359
Gait facilitation 273 muscular tightness 359
by guiding pelvis 276f outburst of laughing and crying 359
Gait section 483 pneumonitis 361
Index 503
pusher’s syndrome 360 quick 156

shoulder hand syndrome 357 slow 156
shoulder hand syndrome treatment 357 tongue 321
shoulder pain 354 Iliotibial band 272
subluxated shoulder 355 Impairment 102, 103
thalamic pain syndrome 358 Incoordination 66
contralateral 30 Infraspinatus tendon 174f
home treatment Inhibition 113
demerits of 385 Inhibitory tapping 116
merits of 384 Integumentary system 1
plan 386 Intercostal stretch 142
problems associated 386 Interferential therapy (IFT) 355
left 67, 70 Interphalangeal flexion 75
physiotherapy for Intracerebral hemorrhage 76
at patient’s residence 139 Irradiation 118
neurointensive care unit (NICU) 139 Isokinetic training, scapula dysfunction 365f
outpatient-based department of the
physiotherapy clinic 139 J
transient care unit (TCU) 139
Jaw movements 315
wards 139
Joint compressions 116
right 67, 69, 85f
treatment
K
bilateral approach 111
Bobath concept 112 KAFO 371
concept 115 dynamic 372
principles of 113 Knee extension
unilateral approach 110, 111 controlled in long sitting 206f
Hemispheric stroke scale 456 with dorsiflexion 189
Hemivisual neglect 55t Knee flexors 272
Hemorrhage 461
subarachnoid 32, 47, 76, 99 L
Hepatic dysfunction 44 Left lower extremity extension 244f
Hip and knee flexion 189 Lesion sites, medulla 53t
Hip external rotators 272 Limb ataxia 474
Hip flexors 272 Limbic system
Horner’s syndrome 58t associated signs and symptoms 15t
Hunt and hess scale 461 functions 15t
Hydrotherapy 369 Lipohyalinosis 34
Hyperactive tendon reflex 50 Lips, stimulation of 319
Hypercholesterolemia 98 Liver dysfunction 46
Hyperkinesia 129 Lobe
Hyperlipidemia 35 frontal, functions 14t
Hypertension 76 occipital
Hypertonia 86 associated signs and symptoms 14t
Hypokinesia 129 functions 14t
Hypothalamus 6
parietal 12f
Hypotonia 116
functions 14t
I temporal, functions 15t
Low back extensors 272
Icing 156 Lower extremity control 187
of lips 321, 321f Lower rib cage elevation 153f
oral cavity 321 Lower trunk, activation of 180
Lumbar lordosis 207 Moyamoya disease 36

Lumbar puncture 47 Muscle
biceps 409
M buccinator, PNF for 318f, 318
Maitland techniques 356 corrugator, PNF for 316f
Mat activities 242 deltoid 175
Mathew stroke scale 462 depressor angulioris, PNF for 318f, 318
Medicine ball 162 frontalis PNF for 316f
Medulla oblongata 6 infraspinatus174f, 175
Medullary syndrome intercostal 165
lateral 56t latissimus dorsi 63, 175, 405
medial 56t levator angulioris, PNF for 317f, 317
unilateral 57t levator labii superioris, PNF for 317f,
Melas 39 317
Meninges, of brain 3 scapulae 177
Meningitis 32 mentalis, PNF for 317f, 317
Metacarpophalangeal (MP) extension 75 of facial expression 124, 315
Metamorphopsia 55t of mastication 124
MFR pectoralis major 175, 177, 178, 405
biceps 158, 159f procerus, PNF for 318f, 318
brachialis 158 quadriceps 132
coracobrachialis 158 control in long sitting 205
for extensor thrust 158 rectus femoris 272
forearm flexors 158 rhomboids 177, 178
gastrocnemius 158 major 175
patellar tendon 158 minor 175
pectoralis major 158 serratus anterior 63, 175, 177, 178, 226,
plantar aspect of sole of foot 158 285
quadriceps 158, 158f sternocleidomastoid 164, 218
sternocleidomastoid 158 sternomastoid 43
techniques 133, 156, 157 subscapularis 174f, 175, 405
to long flexors 159f supinator 409
to upper extremity 157f supraspinatus 175
Midbrain 6, 9 teres
Midpontine syndrome, medial 58t major 63, 174f, 175, 405
Millard–Gubler syndrome 53t minor 175
Mini-mental state examination (MMSE) 464 transversus abdominis 214
interpretation of 465 trapezius 43
Miosis 56t middle 174
Mirroring movements 251 muscle 164
of right upper extremity 251f upper 174
Mitochondrial myopathy 39 triceps 156
Mitral valve prolapse 33 work patterns
Modified Ashworth scale (MAS) 376 heavy work 123t
Modified Rankin scale (MRS) 466 light work 123t
Motor assessment scale (MAS) 82, 467 zygomaticus major, PNF for 318f, 318
Motor control evaluation 398 Myelography, spinal cord 46
Motor cortex 12f Mylohyoid 323
Motor learning strategies 135 Myocardial infarction 40
Motor relearning 368 Myocardial ischemia 44
Motricity index 471 Myoclonic syndrome 58t
Index 505
Myostatic contracture 398 Nystagmus 56t, 59t

Myotatic stretch reflex 50 horizontal 58t
vertical 59t
N
Naloxone 99 O
Near infrared spectroscopy (NIRS) 8 Obstacle walking 292
Neck stretching 218 Occipital lobe syndrome 342
Neglect syndrome 459 Ophthalmoplegia, internuclear 58t
Neonatal reflexes 21, 23 Optic chiasma 7f
asymmetric tonic neck response 22, 23 Orbicularis occuli
moro reflex 21 lower, PNF for 317
palmar grasp 22 upper, PNF for 316f
plantar grasp 22 Orbicularis oris 317
rooting reflex 22 Orgogozo stroke scale 475
sucking reflex 22 Orthosis 370
walking reflex 22 ankle-foot 275
Nerve dual channel 275
abducent 43 molded 275
auditory 43 plastic spiral 275
cranial deficit 53t factors responsible for using 370
facial 43 knee-ankle-foot 275
glossopharyngeal 43 types of 370
hypoglossal 43 Oscillopsia 59t
oculomotor 43 Osteoarthritis 122
paralysis 53t
olfactory 43 P
optic 43 Pain score 376
spinal 44 Palinopsia 55t
trochlear 43 Paralysis 139
ulnar, anesthetic block of 411 complete 473
vagus 43 leg 53t
Nervous system minor 473
central 1 of arm 53t, 56t, 58t
functions 19 of face 53t, 58t
peripheral 1 of leg 56, 58t
Neural tissue stretch 160 of muscles of mastication 59t
femoral nerve 161 of vertical eye 56t
median nerve 160 Paresis 65
obturator nerve 161 Parkinsonian mask 128
radial nerve 160 Parkinsonism 103, 16t
sciatic nerve 160 Passive ranges of motion exercises 148
ulnar nerve 160 ankle
Neurilemma 12 distal interphalangeal 149
Neurological examination 43 elbow joint 149
Neuromuscular electrical stimulation (NMES) foot and toes 149
363 head and neck 148
Neuron 10 hip joint 149
Neurorehabilitation 61 interphalangeal (IP) joints 149
Neurosurgery indications 99 knee joint 149
NIH stroke scale (NIHSS) 45, 472 metacarpophalangeal 149
NPF, basic procedures 118 proximal interphalangeal (PIP) joints 149
radioulnar joint 149 Plantar flexion

scapulae 148 in prone lying 188f
shoulder (glenohumeral) joint 149 in standing 267
subtalar joints 149 Pneumonitis 142
trunk 148 PNF 117, 142
wrist joint 149 PNF activities 298
Patterns of behavior bilateral leg patterns for trunk
brain left 72t in lying 312
brain right 72t in sitting 312
Pefrontal cortex 12f chopping in lying 311
Pelvic clock exercises 194 chopping in sitting 311
Pelvic tilt extension abduction
anterior, sitting 208f external rotation 305
lateral, active 213f internal rotation 307
lateral, assisted 213f internal rotation with elbow extension
posterior, sitting 208f 301
Pelvis internal rotation with knee extension
depression 307
anterior 195f, 195 internal rotation with knee flexion 308
posterior 196 with knee flexion 310
elevation with knee flexion bilateral
anterior 196f, 196 asymmetrical 309
posterior 195 flexion abduction
Perception 326 external 302
Perceptual disabilities, site and side of lesion external rotation 298
327 external rotation at end ranges, lying
Perinatal (birth) asphyxia 10 prone on elbows 303
Peripheral blood circulation 148 external rotation bilateral asymmetrical
Pharyngeal peristalsis 71 302
Pharyngeal secretions 142 external rotation with elbow extension
Phenol injection 401 299, 300
Physical therapy assessment 77 external rotation with elbow flexion
of communication ability 78 300
of functional 82 external rotation with knee extension
of gait 82 306
of joint mobility 80 external rotation with knee flexion 305
of mental status 78 internal rotation 303
of motor control 80 internal rotation with knee extension
of movement 304
of arm and shoulder girdle 88 internal rotation with knee flexion 304
of pelvis, leg and foot (prone) 90 with knee extension 311
of pelvis, leg and foot (supine) 90 with knee extension bilateral
of wrist and fingers 89 asymmetrical 308, 309
of normal postural reflex mechanism 84 PNF techniques 119
sitting tests on chair 91 combination of isotonics 119
standing tests 91 contract-relax 119, 120
Physical therapy, goals 152 goals of 121
Pia mater 3 hold-relax 119, 120
Pineal gland 6 repeated stretch 119, 120
Pituitary gland 7f replication 119, 120
Index 507
reversal of antagonists 119 Reflex sympathetic dystrophy 75

rhythmic initiation 119 Rehabilitation activities
Polyarteritis 35 in sitting
Polycythemia rubra vera 33 functional activities arranging jigsaw
Pons 6, 7f puzzles 251
Pontine syndrome functional activities arranging playing
lateral mid 59t cards 251
lateral superior 58t functional activities dressing up 251
medial inferior 59t functional activities hand activities 251
medial superior 57t functional activities stacking the beads
Pontomedullary syndrome, lateral 57t and rings 251
Post-fractures 122 functional activities, grooming 251
Postural reflex mechanism 113 lying to sitting using trunk 200
Premotor cortex 12f moving in sitting position 217
Pressure tapping 116 moving lower limb 214
Primary auditory cortex 12f moving sideways 202
Primary somatic sensory cortex 12f shoulder activities 220
Primary rami simultaneous activation of upper limb
anterior 124 and trunk 208
posterior 124 sitting from side-lying 201
Primary visual cortex 12f sitting in bed 202
Prone kneeling sitting in chair 215
activities in 243 transfer activities 203
contralateral upper and lower extremity upper extremity control 204
movements in 244f upper extremity placing 211
with right lower extremity extension 244f weight transference on affected upper
Prone walking, with upper limbs 253f limb with reachouts 216
Proprioception 117 weight-bearing through upper
impaired 326 extremities 210
Prosopagnosia 55t, 342 wrist and fingers extension 221f
Prothrombin time 46 in standing
Ptosis 56t ascending stairs 281
Pulmonary embolism 73 assisted activities with table 261, 262f
Pursed lips 143 descending stairs 281
dynamic balance activities 281
R hand functions 290f
Ramiste’s phenomenon 65 pelvic alignment in 259
Range of motion exercise, for lower extremity plantar flexion 267
151f posterior pelvic tilts against wall 267
Receptors 124 selective knee flexion 268
cutaneous 124 standing from a chair 256
golgi tendon organs (1B) 127 standing from high bed 255
in dermis and joints 127 step-up activities 264
in special sense organs 128 training for taking steps 270
labyrinthine system 128 unilateral weight bearing 260
muscle spindles weight bearing on affected leg 265
quick unexpected stretch 126 weight bearing on extended arm 263
slow full stretch 126 Rehabilitation
Reciprocal innervation 118 community-based 102
Reciprocal stimulations, to muscles 113 goals of 314
index 490 Right-left discrimination 329, 333

institution-based 102 treatment 333
medical 101 Rivermead mobility index 478
medicine 100 Rood approach 122
principles of 100 Rood techniques 128
orofacial 314-325 Rotator cuff muscles 174
outreach-based 102
physical 101 S
psychological 101 Scandinavian stroke scale 480
serratus anterior 178, 179f Scapula protraction 146
sexual 101 Scapula, mobilization of in side-lying 187f
social 101 Scapular clock exercises 175
subscapularis 180 Scapular mobilization 148, 150, 172
trapezius anterior elevation 175, 176f, 177f
lower 179f, 179 posterior depression 175, 176f
middle 178, 179f posterior elevation 178f, 178
vocational 101 Scapular muscles
Released grasp reflex 130
from behind 174f
Residual deformities
from front 174f
ankle
Scapular retraction
cavus 415
in sitting 205f
clawfoot 415
protraction 205f
equinus deformity 414
Scapular retractors 62
varus 414
Selective trunk activity 163
elbow
Sensation 326
functional elbow lengthening 407
Sensation loss, compensation for 133
nonfunctional elbow release 408
spastic extension 408 Sensory evaluation 398
spastic flexion 407 Sensory examination 79
foot deformities in nonambulatory patient Sensory stimulation 134f
415 Sherrington’s principle 86
forearm spastic Shoulder
pronation 408 adductors 62
supination 409 depressors 62
hand 410 elevation activities 151
spastic thumb-in-palm deformity 410 external rotation
hip activities 224
adduction deformity 412 movement 224
flexion deformity 413 hand syndrome 355
knee internal rotators 62
dynamic stiff-knee gait 414 subluxation 74
flexion deformity 413 tips aligning 165f
management of 403 Shunting 113
shoulder 404 Sick sinus syndrome 36
adducted 405 Sickle cell anemia 39
adhesive capsulitis 406 Sickle cell disease 33, 35
internally rotated 405 Side-lying activities 170
spastic abduction 406 to affected side 171
Rheumatoid arthritis 122 to sound side 171
Rib cage alignment 165 Simultagnosia 55t, 342
Rib cage elevation 153f Sinuses, frontal 2
Index 509
Skin 1 Stroke 47
layers of 3f bedside assessment of 41
Skull 2 definition 30
Somatagnosia 329 diagnostic tests 45
assessment 329 hemorrhagic 31, 45
Somatosensory dysfunction 326 impact scale 485
Souques’ phenomenon 65 in children 38
Spasm frequency (SF) score 376 in young Indian population 38
Spasticity 60, 129 ischemic 30, 39, 45, 47
Spasticity evaluation 398 acute 42
Spasticity management 400, 402 causes of 35
botulinum toxin 401 less frequent causes of 32
casting 402 medical management 98
focal treatments 401 mimics 38
neurolytic agents 401 orthopedic management of 397
oral agents 400 prevention 52
phenol 401 prone population 33
blocks 401 recovery 76
Spatial disorientation 337 sequential stages 60
assessment 338 threatened 36
treatment 338 thrombo-emobolic 76
Spatial relations deficits 335 types of 30
Spatial summation 118
with atypical presentation 39
Speech disorder 352
Subarachnoid space 4, 4f
Spinal cord segments 44
Successive induction 118
Splint
Sucking reflex 55t, 320
air 375
Supraspinatus tendon 174f
cock-up 371, 372
Suprasylvian speech area 54t
dynamic
Sustained stretch
functions of 371
of upper extremity 162f
thumb 373
technique 161
wrist flexion-extension 372
Swallowing reflexes 71, 320
functional position 372
inflatable pressure 375 Sweat glands 1
lower limb 372, 373 Swedish knee cage 275
opponens 371, 372 Swing phase 272, 276
posterior knee 372, 373 Synapse 10
pressure 371 Synaptic delay 11
safe position 372 Synergy
static functions of 371 extension 63
upper limb 371, 372 flexion 63
wrist cock-up 371 Syphilis 35
Split anterior tibial tendon transfer (splatt) Systemic lupus erythematosus 32
414
Spontaneous intracerebral hematoma 31 T
Stacking rings 252f Tactile sensation, impaired 327
Stance phase 272, 276 Tactokinesthetic stimulations 116
Streptokinase 99 Takayasu’s arteritis 35
Stretch reflex Teleopsia 55t
finger extension 227 Temporal arteritis 35
wrist extension 227 Temporal summation 118
Tens, thalamic pain syndrome 364 Trunk, elongation of 186, 194, 195f
Teres major tendon 174f Tubercular meningitis 38
Teres minor tendon 174f Tubing 293
Tertiary syphilis 32 bilateral shoulder abduction strengthening
Texture ball 134f 293f
Thalamic syndrome 73, 56t muscles strengthened 294
Thalamoperforate syndrome 56t abdominals 295
Thalamus 6 adductor magnus 295
Therapeutic guiding techniques 352 biceps 295
Thorax, mobilization of 165, 166f brachialis 295
Thrombocythemia 33 brachioradialis 295
Thrombolysis 45 brevis 295
Thrombosis 8 deltoid 295
Thrombotic thrombocytopenic purpura 35 gastrocnemius 295
Thumb gluteus maximus 295
abduction 229, 229f gluteus medius 295
extension 229
hamstrings 295
Tilt board 283f
iliacus 295
Tinetti balance assessment tool 482
infraspinatus 294
Tinnitus 59t
latissimus dorsi 294
TNS 355
long extensor of wrist and fingers 295
for reflex sympathetic dystrophy (RSD)
355 long flexors of wrist and fingers 295
transcutaneous electrical nerve stimulator longus 295
363 pectoralis major and pectoralis minor
Tone reduction 132 295
Tongue peroneus longus 295
active exercises for 321 psoas major 295
movements resisted 321 quadriceps 295
Tonic Labyrinthine reflexes 64, 128 rhomboids major and minor 295
Tonic lumbar reflexes 64 serratus anterior 294
Tonic neck reflex 63, 64 soleus 295
asymmetric 64 subscapularis 294
symmetric 64 supraspinatus 294
Tonic vibratory reflex (TVR) 127 teres major and minor 294
Topographic disorientation 339, 348 tibialis anterior 295
Total knee replacement surgery 279 tibialis posterior 295
Tracts trapezius upper, middle, lower 294
corticospinal 50, 51 triceps 295
reticulospinal 50 Two-point discrimination 398
rubrospinal 51
vestibular U
reticulospinal 51
spinal 50 Unilateral dyskinesias 39
Transcutaneous nerve stimulation See TNS Unilateral neglect 327
Transient ischemic attacks (TIAs) 30, 35, Unilateral spatial neglect 329
36, 52 assessment 331
Truncal muscles 272 Upper extremity, coordination activities of
Trunk control test 484 248
Trunk rotation 284f Upper limb
using vestibular ball 197f activation 285
with pelvic lifts 198f mobilization 168
Index 511
V resisted
Valsalva maneuver 314 backward shift 233f
Varus foot 83t forward shift 233f
Vasculopathies 39 sitting
Venous sinuses 3 cross-legged 236f
Ventriculostomy 99 to standing 235f
Verbal coaching 314 supine 237
Verbal dyslexia 55 turning on 238
Vertical disorientation Vibratory toothbrush 320f, 320
assessment 341 Visual inattention 330
treatment 341
W
Vestibular ball 231
crossed leg sitting on a ball 235f Weber’s syndrome 53, 56t
diagonal weight shifts 232b Wegener’s granulomatosis 35
extension-abduction ER pattern 237f Weight shifts
flexion of trunk in kneeling position 240f in high sitting 207
hip knee flexion in lying position 241f on elbows 215
lateral pelvic shifts 233f Wernicke’s area 12f
PNF patterns 236f White matter 5
posterior weight shifts assistance periventricular 9
from behind 232f Wood chopping 284f
from front 232f Wrist and finger flexors 62
prone on 239 Wrist extensors, activation of 219

A Practical Guide To Hemiplegia Treatment

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Contents i

Ipsit Brahmachari PhD

The Health Sciences Publisher

© 2015, Jaypee Brothers Medical Publishers

Inquiries for bulk sales may be solicited at: [email protected]

A Practical Guide to Hemiplegia Treatment

reference and progression of therapy with logical reasoning, as assessment

1. Basic Anatomy and Physiology of Human Brain 1

Proprioceptive neuromuscular facilitation (PNF) pattern activities 169

Training plantar flexion 267

Chewing and deglutition 322

Commonly seen residual deformities and their management 404

ANATOMY OF THE HEAD

FIGURE 1.1: Layers of skin

FIGURE 1.2: Bones of the skull

FIGURE 1.3: Meninges

FIGURE 1.4: Cerebrospinal fluid

THE MAJOR REGIONS OF THE BRAIN AND

FIGURE 1.5: Major regions of the brain

FIGURE 1.6: Cerebral hemispheres

 White matter is responsible for communication between cerebral areas and

masses (nuclei) of gray matter. The cerebellum processes impulses received

THE CEREBRAL CIRCULATORY SYSTEM

FIGURE 1.7: Cerebral circulatory system

possibly, near infrared imaging, to detect or image such localized changes

THE NEONATAL BRAIN

Enduring neurodevelopmental disorders can lead to diminished neurological

ASPECTS OF NEUROANATOMY AND

 Supporting tissue: Neurons are delicate, highly specialized structures and

FIGURE 1.8: Areas of brain

TABLE Brain structure, function and associated symptoms

Cerebral Cortex The outermost layer of

Left Hemisphere Sequential analysis:

Right Hemisphere Holistic functioning:

Brain structure Functions Associated signs and

Frontal Lobe Cognition and memory.  Impairment of recent

Language: Motor speech

Brain structure Functions Associated signs and

Occipital Lobe Primary visual reception  Primary visual cortex:

Temporal Lobe Auditory receptive area  Hearing deficits

Brain structure Functions Associated signs and

Basal Ganglia Subcortical gray matter  Movement disorders:

DEVELOPMENT OF MOVEMENT, POSTURE

 Midline orientation: It is the point of references for movement over a base

prehensile motor activity. Inhibition is a balance of activity between inhibitory

The Asymmetric Tonic Neck Response (ATNR)

The asymmetric tonic neck response (ATNR) is a posture seen frequently

DISCUSSION OF DEVELOPMENTAL SEQUENCES

The Mixture of Flexion and Extension Components

Proximal Fixation and Distal Freedom and Vice Versa

done by various authors on the developments of prehension. The hand activities

THE CLINICAL VALUE OF KNOWLEDGE OF

he is more likely to be successful if he has knowledge of the way in which

circumscribed areas of dilated and thin-walled vessels which can be demonstrated

Subarachnoid Hemorrhage (SAH)

LESS FREQUENT CAUSES OF STROKE

THE STROKE-PRONE POPULATION

RISK FACTORS FOR

CAUSES OF ISCHEMIC STROKE