HANDLING OF THE PATIENTS. SPECIFIC DISEASES

HEMIPLEGIA

4.4.1 Help by therapists: Always assess the amount of voluntary activity in the paretic limb so you know what you may demand from the patient. At the start of LB therapy there is to decide on the initial regimen:

4.4.1.1 Which leg to work first
If the less affected limb does not step properly by itself and the patient does not properly load it, i.e. does not rely on it, first train this limb. Have the patient concentrate on this limb and "actively" work with it till it carries load etc. During all this time take care of the other leg by passively moving it. During this period either two therapists have to work the patient, if only little help is needed for the less affected limb, one therapist can manage. As soon as the less affected limb moves more or less correctly (which usually happens within a few or even a single session), focus is laid on the paretic limb.

Paretic limb: Depending on the degree of paralysis, move passively till some tonus is built up during stance phase.Tapping might help to increase tone. As soon as voluntary activity starts, it must be verbally encouraged. It is important to have the active phase done by the patient and the therapist has to learn when to step in with her/his own help in due time to produce a smooth and increasingly symmetric stride. If voluntary activity can be elicited in resting position (while sitting), you know what you can demand. To increase stance length of the paretic limb, have the patient perform excessive and prolonged hip flexion with the non-paretic contralateral limb to enforce prolonged stance phase of the affected limb. "Make yourself large" is a verbal command quite often helpful. Support heel strike at the beginning of stance, also support knee extension and hip flexion (similar to SCI patients, see above), but always with demanding maximal initial effort from the patient. In case of strong extensor tonus which hinders hip flexion, try to break this by inward rotating the tibia at the end of stance (you will be surprised how effective this can be).

The commonly present circumduction of the affected limb may be avoided by the therapist pulling down on the harness and at the same time with the other hand support hip flexion.

Facilitation of rump, pelvis and limbs according to BOBATH principles may be applied by a second/third therapist standing behind the patient during LB locomotion.

Patients with deficits in perception (Wahrnehmungsstörungen) might react better to "indirect" than to "direct" commands: Verbal commands like "hip flexion now" or "extend the knee" might be replaced by commands like: "Try to climb a step" (for hip flexion), "make yourself larger", "grow" (during stance phase) etc..

When the patient mounted in the harness with symmetric suspension still looks very unsymmetrical, one might try asymmetric suspension (not more than 3-5 kg difference between left and right).

As described for SCI, the therapist sitting at the side may shift body weight by pulling/pushing the patient onto the paretic limb with her hand on the harness. Help for loading the paretic limb may come from the patient if he is able to push himself over to the affected side with his laterally (on the frame) positioned arm.

4.4.1.2 Paretic arm: When possible, symmetric placement of both arms on the frame (sides or front) is the first choice, but check that tonus in the paretic arm does not go up significantly. If this setting is not practical (flaccid arm or too high tonus), the arm may be put in a sling or on a board mounted in front of the patient or may hang down.

4.4.1.3 Flaccid shoulder: May be stabilized by rubber bands (rucksack bandage) with KLETT fixation. The aim is to have a better symmetry in the shoulder girdle.

4.4.1.4 Pushers: Have non-affected arm brought over the head of the patient to straighten his rump and become more symmetric (but patient must not pull himself up): This might help to maintain/establish symmetry with pushers when the patient pushes over to the affected side.

Quite effective: Enhance and prolong swing phase in the non-affected side (see above).

4.4.2 Speed: As with SCI patients two speed ranges should be applied (see above): Low speed with as little help by the therapists as possible to allow a long stance phase and sufficient time to shift body weight. High speed (up to about 1.5 km/h): 2 - 3 therapists if necessary, one shifting body weight from behind, two for setting limbs. However, make sure that the patient maintains his active effort to move limbs and does not quit doing so.