Treatment programs to facilitate selective flexor control of U/E(from stageto stage)

Stage1:passive movement,PNF
Stage2: stage3 stage4
(1) assisted active movement
(2) stimulating activity in the hand with bottlebrush:the therapist draws a bottlebrush
through the patients hand while supporting his arm forward with the elbow
extended.she tells the patient to hold the brush very gently and then,after pulling it
out of his hand,she asks him to grasp it again.
(3) Perform simple tasks with his hemiplegic side guided.for example:eating toast.
even where active movement is stil absent,the patients hand should be guided
during activities as a therepy.the sensation and awareness of the hemiplegic side
can be improved in this way,and the return of potential active movement will be
stimulated.
Stage3:

(1) assisted active movement;resisted movement;active movement;PNF

(2) decrease spasticity:
immerse in ice:placing the patients hand in a mixture of curushed ice and water
causes a reflex relaxion of the flexor spasticity of the fingers and wrist.
(3) Learn normal pattern of movement and posture,inhibit the synergic pattern:
sweep tapping:supporting the patients arm with one hand,the therapist uses her
other hand to sweep firmly and briskly over the extensor muscle group of the
forearm,from its origin above the elbow to the fingertips.as she passes the
wrist,she gives pressure downwards on the dorsum of hand,quickly sweeping
upwards again over the fingers.it can stimulate finger extension.
Using specific therapeutic activities:maintaining the pole in position with the
forearm supinated./flexing the elbow without scapula retraction.
(4) Using the protective extension reaction(in sitting)the patient is asked to lean
towards his hemiplegic side and help to support himself with his arm.the therapist
gives a gentle pull to bring him off balance and then,taking care not to increase
extension of his wrist,pushes quickly up through the ball of his hand.
The treatment can also be applied in standing and in a kneeling position.
It is useful not only for protection.but also for stimulating extensor activity and
speeding uo existing motor function.
(5) perform daily activities with the participate of his hemiplegic side
Stage4:

(1) By using specific therapeutic activities:moving the pole with selective elbow
flexion. /moving the pole with isolated flexion and extension of the wrist.
(2) perform daily activities with the participate of his hemiplegic side
Stage5:
(1)holding the pole still in different positions:the therapist helps him to bend his arm
without losing his grip and without pronation of the forearm and then asks him to stop
in a certain position and to hold the pole in place when she asks him to stop in a
certain position and to hold the pole in place when she takes her hand away.it is
usually easier to begin with his elbow flexed to approximately a right angle.once he
can keep the pole in place without its wobbling or turning towards the vertical,the
therapist moves he thigh away from below his elbow and asks the patient to maintain
the position on his own.the activities becomes progressively more difficult with the
elbow more and more extended.

(2) perform complete daily activities with the participate of his hemiplegic side:such
as making orange juice .
(3)grasping and releasing a wooden pole
Treatment consideration(program) for pusher syndrome(from stageto stage)
Particularly important are those to enable the patient to bear weight on his
hemiplegic leg.eg:bridging,knee extension and retraining balance reactions in all
positions.correct rolling to both sides helps to reestablish head-righting
reactions,and also to orientate the patient in space.guiding his hands during
problem-solving tasks will help to overcome the perceptual disturbances which are
always present.the therapist needs to apply the principle of providing the patient
with correct tacile/kinaesthetic input for his whole body during activity,she guides his
whole body duiring the movement sequence if necessary.attention is given to
restoring facial expression and to improving the quality of the patients voice and
breathing.
1restoring movements of the head:it is essencial to free the head from its fixed
position of lateral flexion and rotation to the sound side,so that particularly side
flexion toward the hemiplegic side without resistance must be maintained or
regained.:while lyingwith the plinth flat,the therapist uses the palm of her hand to
move the patients head sideways./depressing the shoulder girdle with the head held to
the opposite side./mobilizsation continues as the head of the plinth is gradually
elevated./the heardest is raised as far as is possible without losing range of neck
motion.
while sitting:the therapist places her hand against the side of his head and starts to
move it sideways.when dhr encounters a resistance she asks him to relieve the
pressure against her hand,and he moves his head so that the resistance against her
hand decrease.when mobilizing the neck,the therapist will need to give conterpressure against the shoulder on the opposite side to the directionof the lateral flexion.
Active movement of the neck is stimulated by using activities where the patient is
required to turn his head towards the hemiplegic side in order to look an objection.for
example standing with a table in front of him,the patient hits a ball with a pole held in
both hands.
2stimulating activity in the hypotonic trunk side flexors:
1 the patient sits with his hemiplegic leg crossed over the other one.the therapist
stands in front of him,keeping his legs in place with her legs.the with her left hand
round behind his shoulders and her right hand under his left buttock,she helps the
patient to transfer his weight over the right side.when the head fails to come to the
verticle,the therapist uses her left forearm to correct its position.
2 the patient sits with his hemiplegic leg crossed over the other one.Sitting or
standing beside the patient,the therapist asks him to take his weight away from
her.with one hand she presses the muscles of the side of his trunk firmly,using the
web between thumb and index finger to incourage their contraction.the pressure is
applied intermittently.with her other hand she pusher down on the patients
shoulder to stimulate the correct righting reaction of the head,through stretch.
The patient learns to lean towards the sound side,support himself on his elbow
and then return to the upright position without pushing off with his hand,as he
doing so ,the head rights automatically and the trunk side flexors are activated.
3regaining the midline in standing
1 using back slab to activate extension of the hemiplegic knee
2 hitting a ballon with the sound hand elongates the side of the trunk

3 playing a tambourine prevents shortening of the sound side of the trunk

4 with the patients forehead resting on his clasped hands,the patient brings his
elbows down to touch the plinth,and returning to the upright position without
extending his neck.the training can mobilize the trunk and improve active hip
extension in standing.
5 Standing with the back slab,the patient is asked to shift his weight until he feels
his sound hip touching the plinth
6 The patient practices taking weight through the hemigletic leg and can be asked to
kick a football with his sound foot.
7 Standing and moving sideways in a doorway with trunk activity facilitated:trunk
and hip in contact with the frame on the sound side/shifting weight over the
hemigleic leg/additional support provided by the closed door.
8 Hitting a balloon away with the hemiplegic hand:trunk rotated back in readiness fr
the swing,swing forward to hit the balloon.
4starting to walk
The therapist remove the back slab,preferably with the patient still
standing,because otherwise he may lose the feeling for the midline again.the
patient is asked to walk around the plinth,trying to feel his hip against it all the
time.the plinth gives him the orientation he requires to remain in the midline
position.the therapist supporting him from thorax and pelvis .it is easier for him
to walk to set a goal,for example,to his wheelchair placed some distance away.
when kicking a football with his hemiplegic foot the patient transfers his
weight spontaneously over the sound leg.the action of kicking the ball also
facilitates the swing phase of gait,because the movement components are very
similar.
(5)climbing stairs:Climbing stairs stimulates selective movement of the legs and
improves midline or ientation.
Treatment programs to facilitate selective extensor control of L/E(from stageto
stage)