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Paraplegia - Home - KSU Faculty

VIEWS: 75 PAGES: 51

									King Saud University

College of applied medical sciences

RHS 433




                  Paraplegia


                           Done by:

                Abrar Hassan Al-Bazzaz

                  Fai Saleh Al-Sanouna




               Under the supervision of:

                       Prof. Sameeha




                                1
Paraplegia




    2
Definition:

Paraplegia is a partial or complete paralysis of both lower limbs
and all or part of the trunk as a resut of damage to the thoracic or
lumbar spinal cord or to the sacral roots. Paraplegia involves loss
of sensation , the lower the injury, the less the loss of movement
and sensation.

WHY IS IT CALLED PARAPLEGIA?




                                  3
Paraplegia comes from the Greek word "Para" meaning "near,"
and the word "plege" meaning "stroke." Put the two words together
and you have "near stroke." A stroke is a burst artery (a type of
blood vessel that carries blood away from the heart) or a blockage
of an artery in the brain. Because strokes sometimes lead to loss
of movement and/or sensation in parts of the body, the word
"plegia" is used to refer to such conditions.(3).




Causes:

The most common causes of
damage to the spinal cord injuries
generally and paraplegia particularly
are:

-Trauma's such as motor vehicle
accidents, motor bike

-Accidents, falls, sports injuries
(particularly diving into shallow
waters), gunshot wounds, assault
and other injuries and disease such
as poliomyelitis and spina bifida.

-Direct injury such as cuts can occur to the spinal cord, particularly
if the bones (vertebrae) are damaged.

-Fragments of bone or fragments of metal (for example from a car
accident) can cut or damage the spinal cord causing injury.



                                     4
-If the head, neck or back are twisted abnormally,the spinal cord
can be pulled, compressed or pressed sideways , also possibly
causing direct damage.

-The accumulation of blood or fluid can cause swelling within the
spinal cord or spine causing compression of, and damage to the
spinal cord, resulting in an spinal Cord injury. Cells from the
immune system migrate to the injury site, causing additional
damage to some neurons, and death to others, that survived the
initial trauma.

What happen after injury?

Below site of injury:

-Total lack of function.

-Decreased or absent reflexes and flaccid paralysis.

-Lasts from a week to several months after onset.

-End of spinal shock signaled by muscular spasticity,
reflex bladder emptying, hyperreflexia.().

- The prevalence of shoulder pain, reported to range between 30%
and 50% in people with paraplegia, (7-11) may be related to the
repetitive and nearly exclusive use of the upper limbs during self-
care, weight-relief raises, transfers, and wheelchair mobility.
Although shoulder pain may not initially limit an individual's ability
to perform functional activities, if mobility is lost because of
disabling shoulder pain, the physical, social, and vocational
consequences for wheelchair users are significant.


                                    5
- poor rotator cuff or scapular muscle function or muscle fatigue (or
both ).

- This process would be worsened by inflammation, fibrosis or
thickening of the tendons or bursae, or bony osteophyte
formations, all of which may develop with chronic impingement.

Effect Of Spinal Cord Injury On Bowel Control:

The bladder, along with the rest of the body, undergoes dramatic
changes. Since messages between the bladder and the brain
cannot travel up and down the spinal cord, the voiding pattern
described above is not possible. Depending on your type of spinal
cord injury, your bladder may become either "floppy" (flaccid) or
"hyperactive" (spastic or reflex).

The Flaccid Bladder:
A floppy bladder loses detrusor muscle tone (strength) and does
not contract for emptying. This type of bladder can be easily
overstretched with too much urine, which can damage the bladder
wall and increase the risk of infection. Emptying the flaccid bladder
can be done with techniques such as Crede, Valsalva, or
intermittent catheterization. It is very important that you do not let
your bladder get overfull, even if it means waking up at night to
catheterize yourself more frequently.

The Reflex Bladder:
The detrusor muscles in a hyperactive bladder may have
increased tone, and may contract automatically, causing
incontinence (accidental voiding). Sometimes the bladder



                                     6
sphincters do not coordinate properly with the detrusor muscles,
and medication or surgery may be helpful.

Assessment of injury:

Taking a history:

Facts in the history that affect a diagnosis include mechanisms of
injury, preexisiting conditions or disease and advanced age.

Mechanisms of injury:

The forces or stresses producing injury are referred to as
mechanism of injury. Knowledge of their nature assists the
physician with diagnosis and treatment, and they are recorded in
the admission history. A detailed account of the accident is
needed to describe these mechanisms.

These forces often occur in combination. The most common
mechanisms of injury that result in spinal cord injury include:

- Forced flexion or flexion with rotation.

- Forced extension ( hyper extension ).

- Vertical compression.




                                   7
Preexisting conditions or disease:

A number of preexisting conditions or diseases that directly affect
the spine may have predisposed the patient to the initial cord
injury. These high- risk patients are susceptible to cord damage
from relatively minor trauma: a bed ridden patient may even incur
a spontaneous dislocation. If the spine is grossly unstable the
physician may order surgical intervention to prevent neurological
damage.

Anklosing spondylitis is a disease affecting the spinal column
characterized by calcification and ossification of soft tissue and
ligamentous structure. The spinal column is converted in to a rigid
structure when the shock absorbing equalities of the spine are lost.
Relatively minor trauma, particularly in the cervical area, can result
in severe cord damage. Rheumatoid arthritis is a chronic
inflammatory condition may attach the spine and cause
osteoporosis and Ligamentous damage, which cause abnormal
mobility of the spine to the injury.

                                       8
When examining the patient with paraplegia ,PT should test
whether patient can:

- Move hips.

- Flex knees.

- Extend knees.

- Flex feet.

- Extend feet.

- Wiggle toes.




However, following acute trauma
trauma to the spinal cord, most
patients experience temporary
physiological disorgainization of the
cord function ( spinal shock )
characterized by a flaccid paralysis
with depressed or no reflex activity
below the level of the lesion.

The presence of the bullbocavernosus reflex and the anal wink
reflex is the first indication that cord function reorganization is
occurring. The presence or absence of these reflexes helps
differentiate between an upper motor neuron and a lower motor
neuron lesion involving the conus or cauda equine.




                                    9
The presence of these reflexes suggests upper motor neuron
dysfunction, their absence suggests lower motor neuron
dysfunction. The status of these reflexes becomes the main
indicator of the physiological basis for bladder, bowel and sexual
dysfunction.

- BMCA ( brain motor control assessment):

(assessment of motor control in spinal cord injury )

Multi channel surface EMG recordings are used to document the
absence of reflexes and motor unit action potentials during
attempts of volitional movement.

We use a standardized sequence of motor tasks with the subject in
a supine position to characterize features of motor control.(1).

                         Management
Aims of treatment:


Regaining as much strength and function in the trunk and

extremities as possible. Physical therapists (PT) teach the patient

how to keep his muscles strong. These strengthening exercise

involve those for shoulder ( glenu humeral ) joint, for improving the

ability of wheel chair mobility, while the other are designed for

lower limb muscles which enable him to leave his wheel chair,

crutches and other assistive devices gradually as much as

possible.


                                   10
   Shoulder strengthening exercise:


These exercises designed to increase strength and improve the

flexibility and posture of the shoulder complex and trunk, with the

majority of exercises focusing on active glenou humeral motion.(5)


Shoulder flexion:-




                                           Shoulder flexor strenghtening in

                                              supine using free weights




                                           PT aim:- to strengthen the

                                           shoulder flexors.


   PT instructions:-position the pt in supine with their elbow extended.

   Instruct the pt to flex their shoulder.




                                      11
Shoulder flexor / extensor strengthening in prone using free

weights


PT aim: to strength the shoulder flexors / extensors.


PT instructions: position the pt in prone with their arm over the

                                       edge of the bed and their

                                       shoulder flexed. Instruct the pt

                                       to extend their shoulder while

                                       maintaining the elbow

                                       extension.


                                       Lowering and pushing up in

                                                 long sitting


                                       PT aim: to strength the

shoulder flexors/ and or elbow extensors.


                                  12
PT instruction:- position the pt in long sitting with their arms

extended behind them.


Instruct the pt to prop their body through their arms whilest flexing

and extending their elbow.


Progression and variation: less advanced:


1- place the pillow under the knees.


2- use a harness device to help decrease the amount of weight

borne throught the upper limb.


More advanced:-


1- perform same activity in short sitting.


                                  2- place hands further a way from

                                  body.


                                  3- place hands a symmetrically.


                                  Precautions:- preserve tenodesis

                                  grasp.




                                   13
          Shoulder flexor strengthening in sitting using free weights


PT aim: to strengthen the shoulder flexors.


PT instructions: position the pt in sitting with their elbow and

shoulder extended.


Instruct the pt to flex their shoulder whilest keeping their elbow

                                        extended.




                                              Shoulder extensor

                                        strengthening in sitting using

                                                 free weight


                                        PT aim: to strengthen the

                                        shoulder extensors.


PT instructions: position the pt in sitting with their arm beside their

  body instruct the pt to extend their shoulder.




                                   14
                                              Shoulder abductor

                                        strengthening in sitting using

                                                 free weights


                                       PT aim: to strengthen the

                                       shoulder abductors.


                                       PT instructions: position the pt

in sitting with their shoulder adducted. Instruct the pt to abduct

their shoulder with their elbow extended.




                                       Shoulder adduction:-


                                       Shoulder horizontal adductors

                                       strengthening in supine using

                                                free weights


PT aim: to strengthen the shoulder horizontal adductors.




                                  15
PT instructions: position the pt in supine with their shoulder flexed

and horizontally adducted


Instruct the pt to horizontally adduct their shoulder with their elbow

                                                              extended.




                                               Bench press


                                    PT aim: to strengthen the

                                    shoulder horizontal adductors

and elbow extensors.


PT instructions: position the pt in supine with their shoulders

abducted and elbow flexed .instruct the pt to lift the weight above

their chest until their elbows are straight.


 Shoulder internal rotators strengthening in side lying using free

                                weights


PT aim: to strengthen the shoulder internal rotator.


PT instruction: position the pt in sidylying with their elbow flexed.

Instruct the pt to internally rotate their button shoulder.




                                   16
                                    Shoulder

                                     external

                                        rotator

                            strengthening in supine using free weight


PT aim: to strengthen the shoulder

external rotation.


PT instructions: position the pt in supine with their shoulder

abducted and internally rotated and their elbow flexed. Instruct the

pt to externally rotate their shoulder.




                                   17
  Shoulder external rotator strengthening in side lying using free

                                weights


            PT aim: to strength shoulder external rotators.


PT instructions: position the pt in side lying with their elbow flexed.

Instruct the pt to externally rotate their shoulder.




                                          Shoulder external rotator

                                    strengthening in prone using free

                                                  weights


                                   PT aim: to strength the shoulder

external rotators.


PT instructions: position the pt in prone with their upper arm

supported on the bed. Instruct the pt to externally rotate their

shoulder.




                                   18
  Shoulder external rotator                                       .

  strengthening in sitting using free weights with arm supported.


PT aim: to strengthen the shoulder external rotators.


PT instructions:-position the pt in sitting with their shoulder

abducted and supported on table. Instruct the pt to externally

rotate their shoulder.




                              Shoulder retraction:-




                                   19
             Shoulder retractor strengthening in sitting


PT aim: to strengthen the shoulder retractor.


PT instructions: position the pt in sitting in an erect posture.

Instruct the pt to pull their shoulders back wards and down wards.

Ensure that the rhomboids and lower trapezius are activated.


                                - Elbow flexion:-




                                        Elbow flexor strengthening in

                                           supine using free weights


                                Pt aim:-to strengthen the elbow

                                flexors.


                                PT instruction: position the pt in

                                supine. Instruct the pt to flex his

                                elbow.




                                   20
       Elbow flexor strengthening in sitting using free weights


PT aim: to strengthen the elbow flexors.


PT instruction: position the pt in sitting with their elbow and

shoulder extended.


Instruct the pt to flex their elbow.


                              Elbow extension:-


                                Elbow extensor strengthening in

                              supine using free weights


                              PT aim: to strengthen the elbow

                              extensors.


                              PT instructions: position the pt in

supine with their shoulder flexed to 90 degree


Instruct the pt to extend their elbow.




                                       21
    Elbow extensor strengthening in prone using free weights:


PT aim: to strengthen the elbow extensors.


PT instruction: position the pt in prone with their arm over the edge

of the Bed and their elbow flexed.




                                     Elbow extensor strengthening in

                                     sitting using free weights


                                     PT aim:to strengthen the elbow

                                     extensors.


                                     PT instructions: position the pt in



                                 22
sitting with their shoulder flexed and elbow flexed . instruct the pt

to extend their elbow.


Stretching exercise:



                                 Upper chest and abdominal stretch

                                PT aim:-to stretch or maintain length
                                of the anterior trunk muscles.

                                PT instructions:- position the pt in
                                supine with a pillow underneath
                                their back.




                                  23
                  Hip flexor stretch in supine over the edge of plinth

PT aim: to stretch or maintain length of the hip flexors.

PT instructions: position the pt in supine with their legs hanging
over the edge of the bed. Place one leg on a stool to stabilize the
pelvis.

Progression and variation:-

Less advanced:-

Increase the height of the stool.

More advanced:-

Decrease the height of the stool.

Hip flexor stretch in supine by
holding on to knee

PT aim: to stretch or maintain
length of hip flexors.

PT instructions: position the pt in
supine with one knee on their chest

Progression and variation:-

Less advanced-position a knee further a way from the knee.

More advanced: place a weight on the opposite knee.




                                    24
                                             Hip flexor stretch in prone

                                           PT aim:- to stretch or maintain
                                           length of the hip flexors

                                           PT instructions:- position the
                                           pt in prone on a plinth with
                                           pillows under their chest and
                                           knees..

Progression and variation:-

Less advanced:-

1- decrease the number of pillows under the chest and knees.

More advanced:-

1- increase the number of pillows
under the chest and knees.

   Hip adductor stretch in sitting

PT aim: to stretch or maintain
length of the hip internal rotators
and hip adductors.




                                      25
PT instruction: position the pt in sitting facing a plinth . place both
feet up on the

Plinth with their hips abducted and externally rotated.

Progression and variation: less advanced:-

Place a rolled up towel under the knees for support.

More advanced:-

Place a weight on the knees.




             Hip adductor stretch in supine using weight

PT aim:- to stretch or maintain length of the hip adductors.

PT instructions:- position the pt in supine. Place their legs in a
froggie position with




                                   26
Their hips abducted and externally rotated. Place a weight over the
knees.

Hip external rotators

and abductor stretch in supine

PT aim: to stretch or maintain
length of the hip external rotator
or abductor.

PT instruction: position the pt in
supine with their knees bent up
on the bed and rotated to one
side. Place a belt around the
pelvis to keep it flat against the
bed and place a weight on the
top of the knees.

Progression and variation:

Less advanced: decrease the weight on the knees

More advanced: increase the weight on the knees.




                                     27
Hip external rotator stretch in sitting

PT aim: to stretch or maintain length of
the hip external rotators

PT instructions:position the pt in sitting
with one foot on a small stool that is
positioned just lateral to their chair.

Progression and variation:-

Less advanced: use a lower stool.

More advanced:-

1- use a higher stool.

2- place a weight on the knees




                                                          .

                                           Hip internal rotator stretch in
                                                    long sitting

                                          PT aim: to stretch or
                                          maintain length of the hip
                                          internal rotators.

                                          PT instructions: position the
                                          pt in long siting with their
                                          knee in flexion and hip in
external rotation . Place their foot on their opposite leg.


                                    28
Passive ankle movements

PT aim: to stretch or maintain range of
the ankle.

PT instructions: position the pt in sitting
with one foot up on their opposite knee.

Instruct the pt to passively move their
ankle joint through full ROM.

    Hip and knee extensor stretch in supine
                                 using a strap

PT aim:to stretch or maintain length of the
hip and knee extensors.

PT instructions: position the pt in supine
with one leg bent up towards their chest.

Place a weight on the extended knee and
strap around the bed and over the bent
knee.




                                   29
Quadripceps stretching in sitting

PT aim: to stretch or maintain length of
the knee extensors.

PT instructions: position the pt in their
wheel chair with their feet tucked behind
their foot plate.




Hamstring and plantar flexors stretch in
sitting

PT aim: to stretch or maintain length of the
hamstring and ankle plantar flexors.

PT instruction: position the pt in sitting with
their legs raised up on a chair.

Ensure that the ankles are firmly pushed
against the back rest of the chair.

Progression and variation:-

Less advanced: lower the height of the chair

More advanced: raise the height of the chair.

Place the wedge under the feet to increase dorse flexion.




                                    30
                        Lower limb stretch in standing using tilt table

PT aim: to stretch or main tain length of the lower limb muscles.

PT instruction: position the pt in
standing on atilt table with a
wedge under their feet and
straps over their knees, hips
and chest.

Progression and variation:-

Less advanced:

1- decrese the angle of the tilt
table.

2- Decrease the angle of the wedge.

More advanced:1- increase the angle of tilt table. 2- Increase the
angle of wedge.




                                     31
Lower limb stretch in standing using
                      standing frame

PT aim: to stretch or maintain length
of the lower limb muscles.

PT instructions: position the pt in a
standing frame with a wedge under
their feet .ensure that their knees
and hips are extended.

Progression and variation: less advanced:-use a tilt table and/ or
wedge under the feet.

More advanced: use knee extension splints in the parallel bars.

Use a larger wedge under the feet.

Increase the tautness of the hip strap.




                                  32
Lower limb stretch in standing using
parallel bars

PT aim: to stretch or maintain length
of the hip flexors and ankle plantar
flexors.

PT instruction: position the pt in
standing between parallel bars
using knee extension splints.
Instruct the pt to hyper extended
their hips and a lean back wards.

Progression and variation:-

Less advanced: use atilt table or standing frame.

More advanced: place a wedge under the feet.

Treatment may also include gait training and appropriate use of
assistive devices, such as
canes, braces, and walkers,
balance and coordination
activities; transfer training, such
as how to get from bed to
wheelchair or from wheelchair to
car, and training in how to fall to
minimize possible damage(10).




                                      33
Assisstive Devices:

There are a variety of assistive devices that can
improve gait, steady balance, provide extra
support and stability, and avoid fatigue from
overexertion (10).


Canes and Walker:
Canes can support up to 25 percent of your weight. The standard
cane has single shaft, with a curved or flat top. The quad cane is a
one-armed cane with four legs. Quad canes offer varying amounts
of support, depending on the width of the leg base. While this cane
is more stable than standard canes for balance, it is hard to use in
narrow places, like a stair step(10).

Walker:
A walker can support up to 50 percent of your weight. The
standard walker consists of four adjustable legs and handgrips for
each hand and is moved by picking it up and placing the legs flat
on the ground one step at a time. The legs of the walker should be
adjusted so that the handgrips are level with one's hip.
For using a walker, the patient need adequate upper-arm strength,
a reasonable amount of standing balance, and the ability to walk in
the appropriate sequence with the walker(10).

Walker with Wheels:
A walker with front wheels and rear brakes (rollator) may be
preferable for patient who has balance problems, fatigues quickly,



                                  34
or doesn't have enough upper-body strength to use a standard
walker. This walker is moved by pushing it forward as the rear legs
drag along the floor. It is stopped by pushing down on the back
legs. It requires that the user have some degree of control to
prevent the walker from rolling too far forward. It can be difficult to
move on thick carpets. (10)

Walker with a Seat:
This walker can support up to 300 pounds and includes a strap to
secure the person sitting on it. A walker with a seat has front
wheels and rear brakes and works in the same manner as the
walker above (10).

Wheel Chair:

Wheelchairs come in a variety of
sizes, designs, and materials. It is
essential that a wheelchair fits
properly, is comfortable, and meets
one's general functioning needs. If it
is not the appropriate type or fit, a
wheelchair may impair rather than aid in mobility (10).

Orthotics:-

                  Orthotics are special shoe inserts, splints or
                 braces used to help relieve gait problems and foot
                 problems. They can also help increase balance or
                 remove pressure from sore spots. (10)




                                   35
The choice of shoes can also make a difference in ease and
comfort of walking. Styles with toes that curve up (running shoes)
can help reduce tripping and toe wear. High-top shoes or boots
can provide extra ankle support for a steadier gait. Sturdy soles, or
repairing worn areas of soles, may also help. (10).

   • The aim of orthotic management for the paraplegic child
      should be to facilitate and encourage mobility while
      simultaneously attempting to prevent the progression of
      deformity.

Conventional or Traditional Hip Knee Ankle Foot Orthosis
(HKAFO):

   • provides stability and reduce the potential for hip flexion
      contracture.The pelvic band provides some mediolateral hip
      stability, but is typically not successful in controlling anterior
      pelvic tilt.

Conventional orthoses with locked hip
joints were traditionally fitted, but
because of the tendency of patients with
weak hips to fall into a flexed position
while standing, these orthoses are no
longer routinely prescribed.

Hip Guidance Orthosis (HGO):

   • has three mandatory features:

   1) low energy cost at a reasonable speed of ambulation.
   2) independent transfer from chair to walking and vice versa.

                                    36
   3) independent doffing and donning of the orthosis.

The Louisiana State University Reciprocating Gail Orthosis (LSU
RGO):

   • The LSU RGO has been described22 as a lightweight
      bracing system that gives structural support to the lower
      trunk and lower limbs of the paralytic patient while allowing,
      through a cable coupling system, proper hip joint motion for
      walking.




                                     Wheel chair transferring and
                                     preparation for standing:-




                                        Transferring in short sitting from
                                              bed to wheel chair

PT aim: to improve the ability to move from bed to wheel chair.

PT instructions: position the pt in sitting on the edge of a plinth with
their wheel chair close by. Instruct the pt to lift across on to their
wheelchair.

Ensure that one hand is placed on the caution and the other hand
on the plinth.




                                   37
Progression and variation:

Less advanced: use a slide board raise the height of the plinth.

More advanced:-

Lower the height of the plinth.

Transfer on to soft mattress.

Increase the distance between the wheel chair and the plinth.

                                   .




                                   Transferring in short sitting using a
                                               slide board

                                  PT aim: to improve the ability to
                                  move from wheel chair to bed using
                                  a slide board.

                                  PT instructions: position the pt in
                                  sitting on the front edge of their
wheel chair with a slide board between their wheel chair and plinth.
Instruct the pt to lift a cross onto the plinth. Ensure that one hand is
placed on the far wheel and the other hand on the plinth.

Progression and variation

Less advanced: lower the height of the plinth.

More advanced: raise the height of the plinth.


                                    38
                                      Bending the knee in sitting

                                PT aim:- to improve the ability to
                                flex the knee in preparation for
                                standing.

                                PT instruction:- position the pt in
                                sitting with their toes on a line in
                                front of their knees .instruct the pt
                                to flex their knee so that their heel
                                touches a line behind their knee.

Progression and variation:-

Less advanced: place the lines closer to the heel and toes.

Reduce the amount of friction under the foot by using a friction –
reducing device

(Slide sheet)

More advanced: place the lines further a way from the heel and
toes.

Other treatment methods:

Biofeedback: The concept of biofeedback is as simple as looking
in the mirror to watch yourself move your arm or leg. It’s a visual
reinforcement that you are moving your limbs in a desired way. In
biofeedback, a wire electrode connected to a metal plate is
attached to the skin over an arm or leg muscle. When the patient


                                 39
moves this muscle, an electrical signal travels from the electrode
to an attached monitor, where it produces a particular image. The
patient gets reinforcement every time he or she moves the muscle
and creates this image. Biofeedback gives a visual cue that the
patient is moving muscles in a desired way.

-Tilt table:

A table that can be positioned at various angles to the horizontal
helps the cardiovascular system readjust to upright position after a
patient has been in bed for extended periods.

- A progressive resistive exercise:

These are exercise done with weights, pulleys, and special
exercise machines.

- Mat class:

Working on a mat , the patient relearns and practice the skills
needed for independent living: changing position in bed, getting
dressed, moving from one place to another.

- Wheel chair class:

The patient learns to handle a wheel chair, especially on crubs,
ramps, stairs, and in a car.

- Therapeutic exercise, ADL, gait training, Ultra violet light,
supervised hydrotherapy must be related to treatment goals,
bracing, home environment evaluation, equipment fitting,




                                   40
And measurement ( wheel chair, bath ), strengthening and
stretching , ROM exercise with out the assistance from others
whether patient use exercise equipment or participantsin other
forms of physical activities.

- Soft-tissue mobilization:

A massage technique designed to improve movement of and
circulation in the muscles, tendons, and ligaments (6).
- Joint mobilization:

Involves the therapist moving your joints in various angles and
motions (6).
- Proprioceptive neuromuscular facilitation :-

Using multiple muscles together, in smooth logical patterns (6).
- Light active shoulder mobility exercises :-

Using a Swedish aide (a piece of machinery that gives some
support to the arm, allowing you to swing it without having to use
any muscles to hold it up).(6)
- Theraband exercises:

Using a big rubber band to actively strengthen the muscles around
your shoulder blades (6).
- These techniques have three major goals: to improve fluid
circulation, increase range of motion, and enhance muscular
strength. If manual therapy works, we hope it can lead to
improved, pain-free shoulder movement. (6)




                                 41
-Preventive measures are very important to reduce the risk of
pneumonia. These include: percussion and drainage using gravity
to assist; assisted coughing (also termed "quad" coughing);
abdominal binders (to increase the resistance against which the
diaphragm works); and early mobilization with the GIGER MDâ
medical device.

- Curtis et al (44) used a combination of stretching for the anterior
shoulder and strengthening for the posterior shoulder musculature.
Following a 6-month home exercise program, subjects in the
shoulder pain group reported improvements in shoulder pain
during the performance of activities of daily living.

- The strengthening protocol addressed the serratus, middle and
lower trapezius, and glenohumeral external rotator muscles. The
stretching protocol focused on soft tissue structures that are
frequently tightened in people who are long-term wheelchair users:
the pectoralis muscles, the long head of the biceps muscle, the
upper trapezius muscle, and the posterior glenohumeral joint
capsule.

- Treatment of patient in bed:-

- Chest therapy: to maintain good ventilation.

- Passive movement: to assist the circulation and to ensure full
mobility of all paralysed structures.

- Active movement: to maintain or regain muscle strength.

- Physical Therapy seeks to restore or maintain the ability to move.
Therapies generally focus on reducing muscle tone, maintaining or

                                  42
improving range of motion and mobility, increasing strength and
coordination, and improving comfort. Programs may also include
treatments designed to prevent complications such as frozen
joints, contractures (muscles that won’t stretch out) or bedsores(7).

Physical Therapists will assess joint motion, muscle strength and
endurance, posture, pain, heart and lung function and performance
of daily living activities to develop an individualized program.
Therapies may include stretching, strengthening and aerobic
exercises (see Exercise). They may also include gait training and
appropriate use of assistive devices, such as canes, braces, and
walkers (see Assistive Devices); balance and coordination
activities; transfer training — such as how to get from bed to
wheelchair or from wheelchair to car; and training in how to fall to
minimize possible damage. They can also include techniques such
as massage, ultrasound, electrical stimulation or whirlpool. (7)

Sessions with a physical therapist generally last just a few months
or less. Emphasis is usually on the establishment of a home
program with periodic follow-up sessions (7)

A balanced exercise program includes three types of exercise (7):

Stretching/Flexibility Exercises: slow, sustained lengthening of the
muscle (7)

Many experts consider stretching the most important exercise you
can do. That’s because stretching improves flexibility - the ability to
move the parts of your body through their full range of motion.
Stretching can also reduce muscle spasticity and cramps, and may
also reduce problems such as tendonitis and bursitis.(7)


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To be effective, stretching routines must be done regularly, usually
once or twice a day. Stretch as far as you can and hold the stretch
for 10 seconds and then ease back. Each stretch should be
performed slowly, with no sudden jerking or bouncing. Stretching
should also be done before and after other exercises to prevent
muscle strain and soreness and to help avoid injuries (7).

Aerobic Exercises: steady exercise using large muscle groups

Aerobic exercise strengthens your heart and lungs and improves
your body's ability to use oxygen. It also reduces fatigue, increases
energy levels and helps you sleep better, control your weight, and
lift your spirits (7).

It is generally recommended to gradually work up to three or four
sessions per week, each lasting 15 to 60 minutes. Include a 5-
minute warm-up (including stretching) before the activity and 5 to
10 minutes of a cool down (stretching and slower activity)
afterwards. Walking, stationary bicycling, water exercises and
chair exercises are excellent choices.(7)

Walking: Experts recommend walking according to your ability,
comfort and safety. Even short, slow walks can provide benefit.(7)

             Aquatic (water) exercises: Aquatic exercises and
              swimming provide optimal exercise conditions. Water
              eliminates the effects of gravity, allowing weakened
              limbs to attain a greater range of motion. Water
              eliminates the effects of gravity, allowing weakened
              limbs to attain a greater range of motion. Water also



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            helps support the body so there is less stress on hips,
            knees, and spine.
           Exercises in the water can help increase muscle power
            and endurance and help mobilize joints and muscles.
            They also help to relax muscles and improve
            coordination. Warm water (between 83 and 90 degrees
            F) can be especially good for stiff, sore joints.
            Exercises can be done while standing in shoulder-
            height water or while sitting in shallow water. In deeper
            water, an inflatable tube, floatation vest or belt can be
            used for flotation.
           Some of the local chapters of organizations such as
            the Muscular Dystrophy Association, United Cerebral
            Palsy, Arthritis Foundation, YMCA and National
            Multiple Sclerosis Society sponsor aquatics programs.
           Stationary bicycling: Stationary bicycling is a great way
            to improve fitness without putting stress on hips, knees,
            and feet. It can be done in any weather and balance is
            generally not an issue. Add resistance only as you are
            comfortable, and only after warming up.
           Chair exercises: If mobility and balance are big issues,
            consider chair exercises. They can provide a great
            workout and easily incorporate strengthening and
            stretching exercises(7).

Strengthening Exercises - repeated muscle contractions until the
muscle becomes tired




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Strengthening exercises help increase muscle tone and improve
the quality of muscles. This enhances mobility and provides
energy and a positive sense of well-being.

Strong hip and leg muscles are needed to lift the legs to walk and
strong arm muscles are needed to carry out daily functions. Strong
abdominal and back muscles help maintain correct posture and
can counter pain resulting from poor gait, poor posture or the use
of mobility aids.

Knowing which muscles need to be strengthened and how to
perform the exercise without over-stressing the joints is important.
A physical therapist, occupational therapist, and/or doctor can
provide appropriate recommendations.

      Massage therapy: The use of touch and various manipulation
       techniques to move muscles and soft body tissues to relieve
       stress, tension, and pain. For more information, see the
       National Certification Board for Therapeutic Massage and
       Bodywork (7).


      Therapeutic Electrical Stimulation (TES): TES is a technique
       used by some clinicians to improve muscle strength and
       muscle coordination in persons with muscle spasticity. It
       involves administering electrical stimuli to the skin overlying
       weakened muscles (usually muscles opposite to spastic
       muscles). The goal is to increase blood flow to muscles in
       which fibers are atrophied. Although individual cases have
       shown some benefit, studies generally show no benefit (7).




                                   46
Functional electrical stimulation delivers a shock to the patient’s
muscle. The shock activates nerves and makes the muscle move.
Electrodes can be placed on the wrist extensor muscles of the
forearm, for example. The patient relaxes the hand, and then
contracts the wrist extensor muscles to cause movement. This
movement triggers an electric shock to the wrist extensor muscles,
which causes greater movement of the hand than the patient could
make. The benefits are to improve movement and enhance motor
control.   (Rehab    Revolution,    Stroke   Connection     Magazine,
September/October2004).

Chiropractic treatment: A treatment method that depends primarily
on manipulating or adjusting the spine to prevent disease and treat
pain and other ailments. Some people have found that chiropractic
spinal manipulation can help reduce their back pain, and some
claim a temporary improvement in their gait. (7)

ROM exercise:-

the joints, muscles, ligaments, and tendons are not exercised they
will contract/stiffen which will affect patient's body in many ways If
To keep these parts loose range of motion exercises are used.
These exercises should be performed in a smooth motion as quick
motions may damage the joints. As the top of each range is
reached the position should be held for a count of 10.. The
following are a few basic exercises which start from the farthest
point and move towards the center of the body:

Heels:-

   1. Lie flat on your back with your legs straight out.


                                   47
  2. Have your assistant grab the heel, resting the bottom of your
     foot against the inside of their forearm, and place their other
     hand on your shin.
  3. 3-Pull down on the heel and bend the top of the foot towards
     your knee.

Leg Rotation:-

  1. Lie flat on your back with your legs straight and relaxed.
  2. Have the assistant place one hand on the upper portion of
     your thigh and one hand under your thigh. Do not place the
     hands below the knee as this will cause excessive strain on
     the knee joint.
  3. Gently roll the leg from side to side, holding to a 10 count at
     the apex of each rotation.

Hip Extension #1

  1. Lie flat on your back with your legs straight and relaxed.
  2. Working with first one leg and than the other, have the
     assistant lift your leg at the knee until your leg is in an upright
     position.
  3. With one hand on the one the knee and one hand under the
     calf have the assistant push the leg towards your chest,
     holding to a 10 count.

Hip Extension #2

  1. Lie on your side with your legs on top of each other.




                                  48
  2. Have the assistant place one hand on your upper hip and the
     other hand under the thigh, supporting the lower leg in the
     crook of their arm.
  3. Lift the leg to a 20 or 30 degree, holding to a 10 count at the
     apex of the rise.

Hip Extension #3

  1. Lie flat on your back with both legs in an upright position
     (knees straight up and feet flat).
  2. Have the assistant place each hand on a knee.
  3. Move the knees outward, in a wishbone movement, until
     each leg is spread sideways approximately 30 or more
     degrees. As your legs muscles become more accustomed to
     the this stretch the degree of the spreading can be
     increased.

Straight Leg Rise:-

  1. Lie flat on your back with your legs straight and slightly apart.
  2. Working with first one leg and than the other, have the
     assistant kneel between your legs in a slightly hunched
     forward position.
  3. 3-Have the assistant raise your leg and position your heel on
     their shoulder.
  4. 4-With one hand on the leg that is still on the bed and one
     hand under the raised knee have the assistant straighten,
     which will raise your extended leg, holding for a 10 count at
     the apex of the rise.

Trunk Rotation #1


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  1. Lie flat on your back with your legs straight and relaxed.
  2. Have the assistant raise and bend both legs, at the knees,
     towards your chest. Looks like a fetal position.

Trunk Rotation #2

  1. Lie flat on your back with your legs straight and relaxed.
  2. Have the assistant raise both legs, at the knee, until your
     legs are in an upright position.
  3. With both hands on the knees have the assistant rotate your
     legs from side to side, holding to a 10 count at the apex of
     each side rotation.




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