Practical Hemiplegia Assessment 2024 PDF

ASSESSMENT OF HEMIPLEGIA Assessment in neurological physiotherapy is a process of collecting information about disordered movement patterns, underlying impairments, activity restrictions, and societal participation for the purpose of intervention planning. The purpose of assessment is to help th...

ASSESSMENT OF HEMIPLEGIA Assessment in neurological physiotherapy is a process of collecting information about disordered movement patterns, underlying impairments, activity restrictions, and societal participation for the purpose of intervention planning. The purpose of assessment is to help the therapist determine the best intervention. Assessment is arguably the most important step in the rehabilitation process, as our clinical reasoning is based on the information it provides and provides the basis for our decision making throughout the rehabilitation process. Treatment can only be as good as the assessment on which it was based. So, in order for us to progress and manage our treatment plan and ensure we are identifying outpatients’ problems assessment should be an ongoing and continuous, and should allow us to be individualized, patient-centered goals. Let’s see a full sheet of a stroke patient to know the main items in a neurological sheet and how we write down the deficits and problems. After that, we will discuss each item of neurological sheet separately Neurological Sheet Personal: Name: Age: Sex: Occupation: Handedness: Address: Special Habits: Presenting Condition Diagnosis Stroke e.g., Ischemic or Hemorrhagic or Hemiplegia due to Tumor, multiple sclerosis or Traumatic Location e.g. Right of Left Hemisphere, MCA, PCA etc. History of Presenting Condition  Date of Onset of Signs & Symptoms When did initial symptoms appear, did they come on gradually. Did the patient arrived in hospital within first 4 hours of onset of signs  Progression of the Condition Look for changes in the initial symptoms, some prediction of prognosis e.g. Did the patient take TPA, Tissue plasminogen activator within the first 4 hours, was he admitted to ICU, and for how long he was there.  Medical Management how has the condition been managed by the medical team? Did they require neurosurgery such as catheterization or other medical interventions?  Medical Observations Provides information on how medically stable the patient is and on their suitability for assessment especially after hemorrhagic stroke to make sure that the patient is stable medically to begin the rehabilitation program.  Previous Therapy has the patient previously been involved in Physiotherapy? What are their expectations of physiotherapy? Past Medical History  Co-morbidities consider the impact of other co-morbidities on treatment and management.   Previous Neurological Conditions Has the patient had previous neurological conditions which had an impact on their functional abilities and may be useful in predicting future outcomes e.g. previous TIA's, CVA's.  Special Equipment Does the patient require the use of specialized equipment for their management e.g. Suction Units, Special Seating, Orthotics, Gait Aids.  Technology Dependency Is the patient dependent on certain technologies either prior to this admission or new since this admission that you need to be aware of? e.g. Home Oxygen, Pacemaker, Nasal Gastric Tube  Previous Surgery Has the patient had previous surgery which could impact on your assessment and has impacted on their function? e.g., Joint Replacements, Abdominal Surgery.  Risk Factors Does the patient have specific risk factors that could be related to further Neurological Incident. Atrial Fibrillation, Hypertension, High Cholesterol, Diabetes Mellitus. Presence of risk factors impair the recovery potentials.  Medication History Recognise any contraindications for Physiotherapy Treatment e.g., Dantrolene (Medicine) can cause Nausea and muscle weakness. Mobility It is important to understand what an individual’s mobility had been prior to their Stroke and to understand what factors influenced their mobility. We need to ensure we consider mobility in relation to the following areas:   General  Indoor  Outdoor  Steps & Stairs  Falls History Personal Care How did the patient manage personal care prior to the Stroke? Did they need assistance and use any aids/devices to assist?  Washing  Dressing  Continence Other  Vision Do they wear glasses? What do they wear them for? e.g Reading, Driving  Hearing Do they wear a Hearing Aid? Are they wearing it? Is it Switched On / Working  Communication Do they have difficulty expressing themselves or understanding your requests? , Is there motor or sensory Aphasia?  Cognition Does the patient have difficulty concentrating, understanding instructions or following instructions? Consider how this impacts on both your assessment but also on your ongoing treatment planning. MOCA scale can be used to assess the cognition in stroke survivors  Swallowing Do they have difficulty swallowing? Do they cough or choke after eating or drinking? Note: Direct Contact with the physician is required to start with Dysphagia Rehabilitation programs if required.  Fatigue Do they tire quickly?  Pain Is pain an issue either now or prior to Stroke? How does this impact on the patient? Does it have an impact on your assessment? How is pain managed?  Perceptions of own Problems/Main Concern Understanding what is important to the patient is key to successful goal planning and eventually patient motivation for treatment. Ensure you try to determine what the patient perceives to be their main issues and why?   Expectations of Treatment What does the patient expect to get from Physiotherapy? Do they have realistic expectations or understanding of their situation? EXAMINATION The purposes of the examination are to: - Determine the diagnosis and classification within a specific practice pattern. Monitor recovery from stroke. Identify patients who are most likely to benefit from rehabilitation services and the most appropriate choice of a care setting. Develop a specific Plan of Care (POC), including anticipated goals, expected outcomes, prognosis, and interventions. Monitor progress toward projected goals and outcomes through periodic reevaluation. Determine if referral to another practitioner is indicated. Plan for discharge. The comprehensive examination provides the main source of information for clinical decision making. The therapist must differentiate between those impairments that are a direct consequence of the stroke and those that are indirect or secondary, resulting from sequelae or complications that originate from other systems. Aspects of functional performance, including activity limitations and restrictions in participation, are equally important to ascertain. 1-Cranial Nerve Integrity The therapist should examine for: - Facial sensation (CNV) - Facial movements (CNs V and VII). - The presence of swallowing difficulties and drooling necessitates an examination of the motor nuclei of the lower brainstem cranial nerves (CNs IX, X, and XII) affecting the muscles of the face, tongue, larynx, and pharynx. This includes determination of motor function of the lips, mouth, tongue, palate, pharynx, and larynx. - The gag reflex should be examined because hypoactivity may lead to aspiration into the airway. Adequacy of cough mechanisms should also be carefully examined. The therapist needs to be able to recognize the presence of swallowing difficulties to begin early dysphagia management protocol especially if early spontaneously recovery does not manifest. - Speech affection (aphasia or dysarthria) can improve also spontaneously however if some patients does not show any signs of recovery, Speech therapy must be encouraged as the best period of recovery is early first three months typically such as the recovery of motor function of both the upper and lower limbs. - The visual system should be carefully investigated, including tests for visual field defects (CN II, optic radiation, visual cortex), acuity (CN II), pupillary reflexes (CNs II and III), and extraocular movements (CNs III, IV, and VI). Ocular motility disturbances may be present with brainstem strokes, such as diplopia or paralysis of conjugate gaze. Visual field defects (homonymous hemianopsia) need to be differentiated from visual neglect which is a perceptual deficit characterized by an inattention to, or neglect of visual stimuli presented on the involved side.  The patient with pure hemianopsia is typically aware of the deficit and may spontaneously compensate by moving the eyes or head toward the side of deficit; the patient with visual neglect will be unaware (inattentive) of the deficit. The use of prescriptive eyeglasses should be determined before any testing; the therapist should ensure that eyeglasses are worn and clean. 2-Sensation Deficits in somatic sensations (touch, temperature, pain, and proprioception) are common after stroke and it impairs the recovery. The type and extent of impairment are related to the location and size of the vascular lesion. - Symptoms of crossed anesthesia (ipsilateral facial impairments with contralateral trunk and limb involvement) typify brainstem lesions. - Disturbances in cortical sensory modalities (two-point discrimination, stereognosis, kinesthesia, graphesthesia) are also found. Profound sensory impairments will negatively affect motor performance, motor learning, and rehabilitation outcomes and contribute to unilateral neglect and learned nonuse of limbs. Sensory impairment is also associated with pressure sores, abrasions, and shoulder pain and subluxation. Note: Sensory examination according to brunstrom technique includes: Sense of position and movement, tactile localization, finger agnosia, pressure sense of sole of the foot using tongue depressor. 3-Flexibility and Joint Integrity - Active ROM (AROM) may be limited or impossible for the patient in early or middle recovery in the presence of paresis, spasticity, or obligatory synergies that can preclude isolated voluntary movements.  - ROM limitations and developing contractures should be carefully documented. Contractures can develop anywhere but are particularly apparent in the paretic limbs. - In the UE, limitations in the shoulder motions of flexion, abduction, and external rotation are common. - Contractures are likely in the elbow flexors, wrist and finger flexors, and forearm pronators. In the LE, plantarflexion contractures are common. Splinting description is necessary especially in presence of moderate to severe spasticity. 4-Motor Function -Stages of Motor Recovery, Brunstrom stages: Initially, flaccid paralysis is present (stage 1). - This is replaced by the development of spasticity, hyperreflexia, and mass patterns of movement, termed obligatory synergies, all characteristics of upper motor neuron syndrome. Muscles involved in obligatory synergy patterns are strongly linked in a highly stereotyped, abnormal pattern; isolated joint movements outside the obligatory pattern are not possible. - During stage 2 (early synergy), facilitatory stimuli will elicit synergies with minimal voluntary movement. - As recovery progresses, spasticity is marked with full strong obligatory synergies stage 3. As illustration, Stage 3 in upper and lower limb means appearance of flexor synergy during any trial of flexion movement and vise versa. However, in the hand, spasticity creates what is called a hook grasp where the patient use the hand as hook to catch something because of flexion position of wrist and fingers.  - Synergy influence begins to decline in stage 4 as some isolated out-of- synergy joint movements emerge. - During stage 5, relative independence of synergy, spasticity continues to wane, and isolated joint movements become more apparent, and during stage 6 patterns of movement are near normal, see table below. Hand Lower Limb Upper Limb Stages of recovery - Lateral prehension: -Ankle dorsi-flexion with - Shoulder flexion with Stage 4 Grasp something between flexed knee extended elbow the thumb and the lateral -knee flexion beyond 90 -Supination & pronation border of index degrees from sitting from flexed elbow - Can achieve neutral wrist position (Sliding the heel -Moving hand toward the extension behind the chair) sacrum - Palmer prehension: Ankle dorsi-flexion with -Shoulder Abduction Stage 5 Grasp something between Extended knee ( standing with extended elbow the fingers and the palm position) -Supination & pronation (spherical and cylindrical) -knee flexion from from extended elbow Can achieve 30 degrees of extended hip from -Moving hand behind the wrist extension standing position head - isolated finger - Frontal plane isolated Selective isolated joint Stage 6 movements such as hip abduction movement abduction and adduction , - Hip internal rotation thumb opposition, tip to with eversion and Hip tip, and pad to pad external rotation with prehension. inversion. 5 -Tone - Flaccidity (hypotonicity) is present immediately after stroke and is due primarily to the effects of cerebral shock. It is generally short-lived, lasting  a few days or weeks. Flaccidity may persist in a small number of patients with lesions restricted to the primary motor cortex or cerebellum. - Spasticity (hypertonicity) emerges in about 90% of cases and occurs on the sideof the body opposite the lesion.  Spasticity in upper motor neuron syndrome occurs predominantly in antigravity muscles. In the patient with stroke, UE 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 neck and trunk, spasticity may cause increased lateral flexion to the hemiplegic side.  In the LE, spasticity is often strong in the pelvic retractors, hip adductors and internal rotators, hip and knee extensors, plantar flexors and supinator, and toe flexors.  Spasticity results in tight (stiff) muscles that restrict volitional movement. Posturing of the limbs (e.g., a tightly fisted hand with the elbow flexed and held tightly against the chest or a stiff extended knee with a plantar flexed foot) is common with moderate to severe spasticity. Spastic posturing can lead to development of painful spasms (similar to muscle cramping), degenerative changes, and fixed contractures. - An examination of tone is essential. Passive motion testing can be used to determine the presence of hypotonicity or spasticity. Severity of spasticity can be graded on the basis of resistance to passive stretch using the Modified Ashworth Scale (MAS). The position of the affected limbs at rest (resting postures) and during voluntary movements should be observed for tonal influences. 6-Reflexes  Reflexes are altered and also vary according to the stage of recovery. Initially, stroke results in hyporeflexia with flaccidity.  When spasticity and synergies emerge, hyperreflexia is seen. Deep tendon reflexes are hyperactive, and patients may demonstrate clonus, clasp knife response, and a positive Babinski, all consistent findings of upper motor neuron syndrome. -Tonic reflexes may appear in a readily identifiable form similar to that seen in other types of neurological insult (e.g., traumatic brain injury [TBI], cerebral palsy [CP]). Thus, movement of the head or position of the body may elicit an obligatory change in resting tone or movement of the extremities. The most commonly seen is the asymmetrical tonic neck reflex (ATNR) in which head rotation causes elbow extension of the UE on the jaw side with elbow flexion of the opposite skull limb.  7- Associated reactions: will be discussed in details in brunstromme approach 6-Voluntary Movements Abnormal and highly stereotyped obligatory synergies emerge with spasticity following stroke. An inspection of the synergy components reveals that certain muscles are not usually involved in either the flexion or extension synergy. These muscles include the (1) latissimus dorsi, (2) teres major, (3) serratus anterior, (4) finger extensors, and (5) ankle evertors. These muscles, therefore, are generally difficult to activate while the patient is exhibiting these patterns. - Obligatory synergies are often incompatible with normal ADL and functional mobility skills. For example, the patient with a strong LE extensor synergy will have difficulty walking owing to foot planter-flexion and inversion with hip and knee extension and adduction (scissoring gait pattern). As recovery progresses, spasticity and obligatory synergies begin to disappear and more normal synergies with isolated joint control become possible. - Synergistic dominance versus isolated joint control may also vary within a limb (e.g., the shoulder may demonstrate more isolated control than the wrist  and hand). During later recovery, voluntary movements demonstrate isolated joint control and appear more normal in the absence of spasticity and synergy restrictions. 7-Coordination  Proprioceptive losses can result in sensory ataxia. Strokes affecting the cerebellum typically produce cerebellar ataxia (e.g., lateral medullary syndrome (PICA syndrome), basilar artery syndrome, pontine syndromes (Benedict Syndrome) and motor weakness.  The resulting problems with timing and sequencing of muscles can significantly impair function and limit adaptability to changing task and environmental demands. Basal ganglia involvement (posterior cerebral artery syndrome) may lead to slowed movements (bradykinesia) or involuntary movements (choreoathetosis, hemiballismus).  Non-Equilibrium Coordination tests can be used to examine control. The therapist focuses on elements of speed/rate control, steadiness, response orientation, and reaction and movement times. Fine motor control and dexterity should be examined using writing, dressing, and feeding tasks. 8-Motor Programming - Motor praxis is the ability to plan and execute coordinated movement. Lesions of the premotor frontal cortex of either hemisphere, left inferior parietal lobe, and corpus callosum can produce apraxia. - Apraxia is more evident with left hemisphere damage than right and is commonly seen with aphasia. The patient demonstrates difficulty planning and executing purposeful movements that cannot be accounted for by any other reason (i.e., impaired strength, coordination, sensation, tone, cognitive function, communication, or uncooperativeness).  - There are two main types of apraxia: 1- Ideational apraxia is an inability of the patient to produce movement either on command or automatically and represents a complete breakdown in the conceptualization of the task. The patient has no idea how to do the movement and thus cannot formulate the required motor programs. 2- Ideomotorapraxia the patient is unable to produce a movement on command but is able to move automatically. Thus, the patient can perform habitual tasks when not commanded to do so and often perseverates, repeating the activity over and over. Significant information on apraxia will be gained by close collaboration with the occupational therapist. 9-Muscle Strength - Paresis is found in 80% to 90% of all patients after stroke and is a major factor in impaired motor function, activity limitation, and disability. Patients are unable to generate the force necessary for initiating and controlling movement. - The degree of primary weakness is related to the location and size of the brain injury and varies from a complete inability to achieve any contraction (hemiplegia) to hemiparesis with measurable impairments in force production. Weakness is caused primary by decreased the firing frequency of motor units. N.B: Once in the spinal cord some of these fibers cross while the rest remain uncrossed, thereby explaining bilateral weakness. The amount of weakness experienced by the patient may also vary according to the extent and level of inactivity (disuse atrophy) and the specific functional  tasks attempted. Thus, a patient may appear stronger in some tasks than others. - The selective loss of type II fibers results in slowed force production, difficulty with initiation and production of rapid, high-force movements, and rapid onset of fatigue. The number of functioning motor units and discharge firing rates also decrease. This is explained by the presence of transsynaptic degeneration of alpha motor neurons that occurs with loss of corticospinal innervation. 10-Postural Control, Trunk Control and Balance - Postural control and balance are disturbed following stroke with impairments in alignment, stability, symmetry, and dynamic balance common. - The automatic adjustment of postural muscles that occurs normally in preparation for and during a movement task is also impaired. Thus, patients with stroke may lack the ability to adjust and stabilize proximal limbs and trunk appropriately during movement, with resulting postural abnormalities, balance impairments, and increased risk for falls. Common postural alignment deviations following stroke are presented in Table below. Higher postural reactions: A- Righting: alignment of head in upright posture (Face vertical, Mouth horizontal). Adjustment of the head in relation to the trunk and relative to the ground such as during rolling, transfer from supine to sit B- Equilibrium: Keeping COG within the BOS (1st line of defense) using Hip and ankle strategy C- Protective: Creating a new BOS using Upper or Lower limbs using stepping strategy or grasping (2nd line of defense) Trunk Control Levels: Level 1: Assuming of Upright posture Level 2: Ability to move the trunk in all planes and reestablishment of erect posture Level 3: Ability to move upper and lower extremities in all planes while keeping the trunk in balanced state Level 4: Use the trunk as a source of power production such as sit to stand transfer Balance impairments may exist when reacting to a destabilizing external force (reactive postural control) and/or during self-initiated movements (proactive or anticipatorypostural control). Thus, the patient may be unable to maintain stable balance in sitting or standing or to move in the posture without loss of balance. Disruptions of central sensorimotor processing contribute to an inability to recruit effective postural strategies and adapt postural movements to changing task and environmental demands. Patients with stroke typically demonstrate uneven weight distribution and increased postural sway in standing. Delays in the onset of motor activity, abnormal timing and sequencing of muscle activity, and abnormal co-contraction result in disorganization of normal postural synergies. For example, proximal muscles are typically activated in advance of distal muscles or, in some patients, very late. Corrective responses to perturbations or destabilizing forces are inadequate and result in loss of balance and frequent falls. Patients with hemiplegia typically fall in the direction of weakness. Static and dynamic balance control should be examined in sitting and standing. The patient’s ability to maintain a stable position (steadiness) and position (symmetry) within the base of support (BOS) is determined. Dynamic stability control can be examined by having the patient move within a given posture (weight shift) or reach within his or her limits of stability (LOS). The patient should be encouraged to shift weight in all directions, especially to the more involved side where greater impairments are expected. Functional tasks that utilize moving from one posture to another (e.g., supine-to- sit, sit-to-stand) can also be used to examine dynamic postural control. Performance-based tests can be used to examine postural control and balance following stroke. The Berg Balance Scale (BBS) The Performance-Oriented Mobility Assessment (POMA, Tinetti) The Timed Up and Go Test (TUG) 11-Ipsilateral Pushing Ipsilateral pushing (also known as pusher syndrome or contraversive pushing) is an unusual motor behavior characterized by active pushing with the stronger extremities toward the hemiparetic side with a lateral postural imbalance. The end result is a tendency to fall toward the hemiparetic side. Ipsilateral pushing occurs in about 10% of patients with acute stroke and results from stroke affecting the posterolateral thalamus. The result is an altered perception of the body’s orientation in relation to gravity. These patients experience a misperception of subjective postural vertical position, perceiving their body as vertical when it was tilted about 20° toward the hemiparetic side. The visual and vestibular input for orientation perception to vertical remained intact as patients were able to align their bodies with the help of visual cues and conscious strategies. No significant association between ipsilateral pushing and hemineglect, anosognosia, aphasia, or apraxia has been found. Functional skills are significantly impaired for patients with ipsilateral pushing. During sitting, the push results in a strong lateral lean toward the weaker side; when sitting in a wheelchair, this often thrusts the patient over onto the wheelchair arm. In standing, a strong push creates an unstable situation with a high risk of falls because thehemiparetic LE typically cannot support the body weight. During walking, the patient typically exhibits inadequate extension of the hemiparetic LE with inability to transfer weight toward the less involved LE. During swing, strong scissoring (adduction) of the more involved LE is typically evident. The use of a cane during ambulation is problematic because patients use the cane to increase push to the hemiplegic side. Patients with ipsilateral pushing behavior have poorer rehabilitation outcomes with longer hospital stays and prolonged recovery times. They also had significantly lower functional scores on admission and discharge with increased levels of dependence at discharge. However, with training, the brain can compensate well. The syndrome is rarely still evident at 6 months. 12-Gait and Locomotion Gait abnormalities includes: Stance Phase: No heel contact, excessive heel inversion during initial contact, Loss of knee flexion in loading response phase, Excessive knee hyperextension and lateral lurching in mid stance, early heel rise and no pushing off by the ankle, Excessive lateral rotation position. Swing Phase: Hip circumduction, hip hiking, Absence of hip flexion, knee flexion, and ankle dorsi-flexion. Step length: Unequal step length (Longer step with the unaffected side). Cadence and velocity: Decreased Weight bearing symmetry ratio while walking: decreased over paretic limb. -Classification of Walking Handicap after Stroke: Not all stroke survivors can walk individually again, only 80% of patients do. However, 20% of patients become wheelchair depended.The use of functional categories (physiological walker, household walker, and community walker) provides a useful method of identifying customary level of walking at home andin the community. Walking handicap, defined as the social disadvantage as a result of limitations in walking ability, can also be identified. Factors that differentiated household from community ambulators included strength, proprioception, isolated knee control (flexionand extension), and velocity. This classification system can be used to improve communication among clinicians, treatment planning, and documentation, see tables below. 13-Integumentary Integrity Ischemic damage and subsequent necrosis of the skin results in skin breakdown and pressure ulcers (decubitus ulcers). The skin breaks down typically over bony prominences from pressure, friction, shearing, and/or maceration. Intense pressure for a short time or low pressure for a long-time result in pressure ulcers. Friction occurs as the skin rubs or is dragged against the supporting surface, for example, when the patient slides down in bed or is pulled up. Pressure-relieving devices (PRDs) are used to minimize high concentrations of pressure. These include foam pads, alternating pressure mattress, water mattress, air-fluidized bed, sheepskin, heel and elbow protectors, multipodus boots, and wheelchair cushions. Proper use of PRDs and positioning (seating) in the wheelchair should be closely examined. 14-Aerobic Capacity and Endurance A supervised exercise test with electrocardiogram (ECG) monitoring may be indicated for survivors of stroke with cardiovascular disease in the subacute phase. Performance measures include significant ECG changes, HR, BP, Rating of Perceived Exertion (RPE), and other signs of ischemic intolerance. The mode of testing will depend on the individual patient and can include leg cycle ergometry, semirecumbent cycle ergometry, a combination arm-leg ergometer, treadmill (TM) walking, or a seated stepper. If balance is impaired, recumbent equipment or an overhead safety harness on a Treadmill should be used. Test protocols are individualized and are generally submaximal with a gradual progression in intensity. 15-Cognitive function: Stroke patients may suffer from cognitive function that may harden the recovery of these patients. Mini-Mental State Examination (MMSE) scale is a set of 11 questions with total score of 30. Unilateral visual neglect and amnesia are common disorders that can be detected using this scale. 16-Functional Status Information on functional disability following stroke is typically gained through performance-based measures. The Barthel Index and the FunctionalIndependence Measure (FIM) have been extensively tested and demonstrate excellent reliability, validity, and sensitivity. Practical Part: Flaccid stage: Goals: 1. Prevent respiratory, circulatory and skin complications: Some patients has hemi-diaphragmatic weakness where breathing exercises and incentive spirometer are recommended. Changing position every 2 hours to prevent skin ulcers in addition to usage of air mattress. Passive ankle pumping exercises to prevent edema and DVT 2. Minimize the effect of tonal abnormalities: positioning and splints 3. Maintain full ROM and prevent deformities: Gleno-humeral joint, scapula-thoracic, ankle planter flexors, and hip external rotators 4. Early mobility: Rolling and Early bed activities 5. Promote awareness and active movement of hemiplegic side: Bilateral upper limb elevation, NMES, Facilitation techniques if the patient can assist. 6. Improve trunk control: Active assisted trunk flexion, extension, side-bending, and rotation - Positioning: - One of the most important components of physical therapy Interventions is the proper positioning of the patient. Positioning should be started immediately following the patient’s stroke and should continue throughout all phases of the patient’s recovery. Proper positioning out of the characteristic synergy patterns assists in stimulating motor function, increases sensory awareness, improves respiratory and oromotor functions, and assists in maintaining normal range of motion in the neck, trunk, and extremities. Additionally, common musculoskeletal deformities and the potential for pressure ulcers can be minimized with proper patient positioning. The patient should be alternately positioned on the back, the involved side, and the uninvolved side. -Rolling: A) Rolling to the involved side: Rolling to the involved side is often easier because the patient initiates the movement with the uninvolved side of the body. The activity begins with the patient turning the head to the side toward which the patient is going to roll. Head and eye movements provide strong cues to the body to prepare for movement. Head turning also helps to unweight the opposite upper extremity and facilitates upper trunk rotation. The patient should be encouraged to use the uninvolved upper and lower extremities to assist with the transition from supine to side-lying on the involved side. Patients often want to reach and hold on to the bed rails to assist with rolling. To roll over, the patient reaches across the body with the uninvolved upper extremity and flexes and adducts the uninvolved hip and knee. This provides the patient with the momentum needed to complete the roll. B) Rolling to the uninvolved side: Rolling to the uninvolved side is usually more challenging for the patient. Again, the activity must be initiated with rotation of the head to the side toward which the patient is rolling. Patients with neglect often have a difficult time initiating cervical rotation for head turning. The patient should be encouraged to look in the direction in which he or she is moving. It is also important to note the position of the patient’s eyes during this activity. If neglect is significant, it may be difficult for the patient to move his or her eyes past midline to focus on items, tasks, or individuals on the involved side. To initiate rolling to the uninvolved side, the patient is encouraged to assist as much as possible. -Early bed activities: Bridging exercises with tibial approximation, lower trunk rotation from crock- lying position, straight leg raising for non-affected limb, facilitation of hip extension over the edge of the bed, bilateral upper limbs elevation Hip extension over the edge of the bed: - The benefit of this exercise is to facilitate early activation of the gluteus maximus and hamstring muscles. - Patient position: supine lying position with the affected limb outside the plinth, and supported on a small step stool. - Hand placement: one hand supports the affected knee and the other hand supports the foot. - Application of exercise: the patient pushes down with the affected limb against the step stool; the therapist can palpate the gluteus maximus to assess if the patient exhibits effort or not. Straight leg raising of the non-affected limb: - The benefit of this exercise is to facilitate early activation of the gluteus maximus and hamstring muscles and for trunk control. Straight leg raising of the non-affected limb: - The benefit of this exercise is to facilitate early activation of the gluteus maximus and hamstring muscles and for trunk control. - Patient position: supine lying position, with the non-affected leg is extended and the hip and knee of affected limb are flexed, while the affected ankle rested on the bed. - Hand placement: one hand support the affected limb through the ankle, and the other hand palpate the hamstring muscle contraction. - Application of exercise: ask the patient to raise his non-affected limb; the patient will be forced to make weight bearing on the affected limb. Inferior shoulder subluxation: Is defined as inferior displacement of is a humeral head and relation to the glenoid cavity of the scapula. We have to know that the only muscle which is active during the rest among the whole rotator cuff is supraspinatus muscle. As a result, hypotonia of this muscle translate the weight of the upper limb to the Superior part of the capsule causing creeping to this part of the capsule in addition to the superior gleno-humeral and coraco-humeral ligament.. This lengthening of the capsule can be increased by changing of the alignment of the scapula because of the hypotonia of upper trapezius muscle. Management:  NMES for Supraspinatus and posterior fibers of deltoid  Early facilitatory and active assisted exercises for rotator cuff muscles mainly supra-spinatus , deltoid muscles and upper fibers of trapezius muscle  Humeral cuff sling for hemiplegia or rigid tapping  Good support of shoulder during sitting over a high pillow  Good handling during transfer Humeral cuff sling for hemiplegia Spastic stage:  Hemiplegic stroke impairs the normal excursion of movements and limits the freedom of movements to certain pattern called abnormal synergy (Flexion or extension). Stroke patients may want to move their extremity to one direction however the extremity does not follow.  This pathology can be illustrated by abnormal resting tone (Imbalance) between agonist and antagonist (Spasticity) making the hypertonic muscle more ready for contraction, Pathological co-contraction between agonist and antagonist which means loss of reciprocal inhibition and non-apparent joint movement, primary muscle weakness (loss of firing frequency in spite of normal recruitment), and loss of normal signals to cerebellum from  proprioceptors that organize the action and sequence of muscle contraction between pyramidal (mover) and extra-pyramidal (Stabilizer) systems.  Stroke does not only cause a neural insult but also it causes secondary musculoskeletal disorders including muscle tightness (reversible)/contracture (Irreversible), muscle weakness (disuse muscle weakness), and joint stiffness because of immobilization that may worsen to joint deformity especially such as elbow, wrist and finger flexion deformity in addition to ankle planter-flexion deformity. - Consequently, our plan of treatment will try to control /manage these problems as much as we can with clear illustration to each patient that our interventions may restore the normal function or may not. If we could not, patients have to adapt using other substitutions or any assistive devices. For example: If the patient walks with drop foot in spite of many trials (time and effort) to improve the ankle dorsi-flexors power, the ideal intervention is to describe a suitable AFO to use while walking. 1- Muscle tone modulation (Facilitatory and inhibitory techniques): - Quick Stretch: using rapid movement for stimulation of muscle spindle manually or by gravity. - Tapping: stroking the muscle or tendon to elicit stretch reflex. Note: Reverse tapping is quick stretching of muscle using gravity such as unlocking of knee and elbow from weight bearing positions. - Prolonged Stretching: inhibition of muscle tone using Golgi tendon organ manually or by splinting - Inhibitory Pressure: inhibition of muscle tone using Golgi tendon organ through positioning the extremity in weight bearing positions such as side sitting for upper limb and quadruped for lower limb. - Old bobath technique: Induction of the reflex inhibiting pattern through proximal (Pelvis and scapula) and distal key points (Thumb and big toe) of control to modulate the muscle tone. It uses postural reactions (Righting, equilibrium, and protective reactions) in different body postures (as Sitting & quadruped) to restore the normal movements. Any abnormal or associated reactions are prohibited. - Brief and prolonged icing, Slow and fast vestibular stimulation, High and low frequency vibration, NMES, TENS, brief brushing, Neural Warmth (Heat Application), lidocaine iontophoresis, Fast and slow rhythm approximation, traction, Muscle relaxant drugs, and botox injections. 2- Joint mobility and Muscle flexibility: - Regular stretching exercises, PROM exercises for joints, and splinting are fundamentals for prevention of joint stiffness and muscle contractures in addition to assisting in restoring active agonist movement by reducing the non-neural resistance that comes from antagonist muscle. Shoulder, elbow, radio-ulnar, wrist, and ankle joints are highly susceptible to get stiff however Latissimus dorsi, pectoralis major, sub-scapularis, pronators, flexors of elbow, wrist, finger, hamstring, adductors, hip external rotators (early improper positioning) and calf muscles are the muscles that common to get shorten. 3- Selective muscle activation: - using Motor Control (Eccentric, Isometric, Concentric) followed by training to perform the stages of recovery tasks for upper limb, lower limb and hand according to brunstrom technique. - The main principle is using gravity to activate the muscle individually away from the synergy.  - If the stage of recovery is three or lower, associated reactions and abnormal reflexes can be used such as tonic thumb reflex and lumber tonic reflex. However, after stage three of recovery, only selective muscle contraction is allowed (Motor Control). - interoceptive methods of facilitation (Muscle spindle) can be used through the whole stages. 4- Group-muscle training and core stability training: - Marching in place, heel rise, mini-squatting against wall, lunge, straight leg raising exercises, cycling, quadruped stability exercises for upper and lower limbs, pushing against wall by both upper limbs, and bilateral upper limbs exercises 5- Task-oriented training (TOT): - Task-oriented training (TOT), proposed by Carr and Shepherd (2003), is one therapeutic intervention used in stroke rehabilitation to improve Upper and Lower extremities motor skills and performance of daily activities in adults with stroke. TOT refers to programs that focus on the massive practice of functional tasks and active participation. Examples: Hook-lying position, bridging, sitting, quadruped-position, kneeling, half-kneeling, standing, sit to stand, single-limb standing, and gait training. Hook-lying position: is a fundamental position to begin bed mobility exercises. This posture can be used to promote stability of the trunk and hips, dynamic postural control of the trunk and lower extremities. Stroke patients may have difficulty maintaining this hip and knee flexion position because of positive supporting reaction when the whole foot touch the bed, extensor muscle spasticity, and hamstring muscle weakness. Early hamstring muscle facilitation, avoiding touching the ball pad of the foot sole (only the heel), and approximation along the tibia to ground to encourage normal sensory input can help to manage these problems. Hook-lying position Bridging: Bridging is an important prerequisite requirement for moving in bed (positional changes), dressing, and for moving to the edge of the bed in preparation for sitting. Bridging involves extending the hips and elevating the pelvis from the support surface with the lumbar spine in a neutral position. The lower trunk/hip muscles (hip abductors and adductors, and internal and external rotators) function to stabilize the hip and lower trunk while the hip extensors elevate the pelvis. The hamstrings keep the knees flexed and the feet positioned for weight bearing, and the ankle and foot muscles stabilize the feet. During bridging, the gluteus maximus is primarily responsible for hip extension because knee flexion places the hamstrings in a position of active insufficiency. Advance to bridging exercises with resistance to pelvis, half-bridging, cross- bridging, Scooting, bilateral combined lower limb rotation in both direction as a preparation for rolling.  Bridging Sitting: The trunk muscles actively maintain upright postural control and core stability, including co-contractions of the trunk extensors (erector spinae muscles) and flexors (abdominals). Activity of the erector spinae muscles is greatest during active erect sitting as opposed to relaxed or slumped sitting. Lower extremity muscles are important stabilizers of the trunk and pelvis. Ankle dorsiflexors (anterior tibialis) and hip flexors (iliopsoas) are activated during backward displacements of the trunk, whereas calf muscles (soleus), knee muscles (vastus lateralis, biceps femoris), and hip extensor muscles (gluteus maximus) brake forward movement of the trunk. When the feet are hanging free on a raised seat, control shifts solely to trunk and hip muscles with limit of stability (LOS) reached much sooner than when feet are in contact with the floor.  Sitting exercises Tactile cues can be used to call attention to missing elements. For example, tapping on the posterior neck and/or trunk can facilitate and engage the extensor muscles. Visual cues can be utilized by having the patient sit directly in front of a mirror. A vertical line of tape applied to a plain shirt worn by the patient can help the patient recognize vertical position. Augmented feed-back should also emphasize positive aspects of performance, providing reinforcement and enhancing motivation. As soon as appropriate, augmented feedback should be reduced or withdrawn. Kneeling & half-kneeling: Before using kneeling exercises, the therapist must consider several important requirements for assuming the posture. Hip extension ROM is necessary; if limitations exist (e.g., hip flexion contractures), the patient’s ability to achieve the needed hip extension will be compromised. Sufficient strength of the trunk and hip extensor muscles is necessary to keep the head and trunk upright and the hips extended. This is particularly important given the relative anterior instability inherent in the posture. Although kneeling provides an important opportunity for improving posture and balance control, adequate stability (static postural control) is needed for initial maintenance of the upright posture. Kneeling & half-kneeling exercises Clinical notes: Focus is on postural alignment and even weight distribution during active kneeling while maintaining the COM over BOS. Hands are resting on ball in front (start position) and knees are in symmetrical stance position. For Weight Shifting, medial/lateral weight shifting in kneeling, the patient actively shifts the pelvis from side-to-side. Anterior/ posterior shifts are accomplished by rolling the ball forward and backward. Weight shifting from kneeling position walking from kneeling position Standing: Postural stability in standing is maintained by muscle activity that includes (1) postural tone in the anti-gravity muscles throughout the trunk and lower extremities and (2) contraction of antigravity muscles. The gluteus maximus and hamstrings contract to maintain pelvic alignment, the abdominals contract to flatten the lumbar curve, the para-vertebral muscles contract to extend the spine, the quadriceps muscles contract to maintain knee extension, and the hip abductors contract to maintain pelvic alignment during mid-stance and during lateral displacements. Modified standing, also referred to as modified plantigrade, is an early standing posture that involves four-limb weightbearing. The patient stands next to a treatment table with both shoulders flexed (45 to 70 degrees), elbows extended, hands flat on the treatment table and weight bearing, and feet in symmetrical stance position. The hips are flexed and the knees extended; the ankles are dorsiflexed. This creates a stable posture with a wide BOS and a high COM. The BOS and the degree of upper limb weight-bearing can be increased or decreased by varying the distance the patient is standing from the table. The patient need not demonstrate complete knee extensor control required for upright standing in modified standing as the position of the COM is in front of the weight-bearing line. This creates an extension moment at the knee, aiding weak extensors. As control develops, the patient can progress from flat hand to fingertip support and from bilateral to unilateral upper limb support to free standing.  Visual feedback for standing alignment Plantigrade standing position To improve knee buckling (flexion) while standing, the patient can assume stepping position where he/she places the sound foot over a small box and paretic lower limb is extended on the ground. At the same time, the therapist is trying to unlock the knee while the patient maintains the extension. Also, maintaining the knee extension with weight shifiting from standing position may help the patient to control any buckling voluntary then involuntary by time. Prevention of knee buckling by therapist’s knee during weight shifting & stepping exercises Squatting and lunge exercises are required to increase the power of quadriceps muscle to control any buckling. Forward and sideward stepping over a small box are the best exercises to strengthen the knee extensors and hip abductors respectively. Standing with Knee recurvatum can be controlled by placement of small towel to raise the heel only to encourage knee flexion while standing training. Weight shifting from standing position Marching and stepping with weighted cuff around ankle Standing balance is a fundamental prerequisite for walking. Therapeutic interventions selected must remediate musculoskeletal impairments that hinder use of the hip, ankle, and stepping strategies while practicing the synergies themselves and reintegrating them into functional movement. Reliance on visual or somatosensory input can be retrained by exposing the patient to conditions that require involvement of the underutilized modality while improving patient confidence under these conditions. For instance, a person who relies on visual information for orientation should practice standing on a variety of surfaces with the eyes closed or with vision distorted (e.g., wearing dark sunglasses). A person who relies on somatosensory information should practice standing on compliant or uneven surfaces with and without visual information. Vestibular inputs can be stimulated by situations that limit use of visual and somatosensory information such as standing on foam with head turning side to side. Squatting against wall Active forward stepping sidestepping for abductors Resisted sidestepping Resisted forward stepping Sit to stand: The sit-to-stand motion is a common movement in daily life and understanding the mechanism of the sit-to-stand motion is important. It consists of four phases as following: Phase I, forward transfer of trunk, hip lifting off the chair and maximal hip flexion; Phase II, transitory knee extension point to maximal ankle dorsiflexion; Phase III , maximal ankle dorsiflexion to point of just standing up in nearly full extension of the knee and hip; Phase IV, stable standing. Foot placement is crucial while performing this task as hemiplegic patients put affected foot anterior in relation to sound one and as a result, majority of raising up forces come from the non-paretic limb. The height of chair must be adjusted from high to low to control the required forces from hip and knee extensors. Muscle activation during the four phases of sit to stand task Gait training: The foundational prerequisite requirements to initiate interventions to improve locomotor skills include appropriate weight bearing status, musculoskeletal (postural) alignment, ROM, muscle performance (strength, power, and endurance),motor function, balance, and static and dynamic standing control. Many of these prerequisites are dependent on intact neuromuscular synergies (necessary for static and dynamic control), intact sensory (somatosensory, visual, and vestibular) systems, and intact central nervous system sensory integration mechanisms. Also required is the ability to safely stand while engaged in Upper limb functional movements (e.g., reaching) under varying environmental demands (e.g., dual-task activity). Locomotor training is initiated once the patient has achieved adequate mobility and stability, with the ability to initiate and control the pelvis and LE in appropriate sequence for swing and stance. Before facilitation of the gait components, certain tasks have to be trained: -HIGH-STEPPING High-stepping is used to reinforce the components of swing and stance and to assist the patient in developing an improved kinesthetic sense of the components of gait. When the hip is brought higher than 90 degrees of flexion, the influence of the cross-extension reflex is recruited, facilitating motor output in extension of the stance LE and flexion of the swing LE. This activity is highly effective in facilitating components of both swing (pelvis anterior elevation with hip flexion, adduction, and external rotation; knee flexion; and ankle dorsiflexion) and stance (pelvis posterior depression with hip extension, abduction, and internal rotation; knee extension; and ankle plantarflexion). The patient stands in a stride position with one foot forward and one foot back. Given the potential challenges to balance during this activity it is safest when initially performed next to a treatment table (for support) or inside parallel bars. The patient is assisted (guided) or resisted (facilitatory) through weight shifting anteriorly onto the forward limb with a high step taken by the posterior limb. Attention must be directed to proper alignment and control of the stance Lower limb. High-stepping can be used to facilitate components of both stance and swing phases of gait. Facilitation of pelvic posterior depression on stance limb and anterior pelvic elevation on swing side. Manual assistance provided to increase hip flexion with facilitation (light resistance) of pelvic anterior elevation on swing side. -FORWARD AND BACKWARD WALKING INITIATION: The patient practices walking forward and backward as a progression from high- stepping. The therapist focuses on appropriate timing and sequencing, beginning with the weight shift forward and diagonally or backward and diagonally with weight acceptance onto the stance limb. The movements are repeated to allow for a continuous movement sequence. -SIDE-STEPPING: Walking sideways is not only valuable for its functional benefits of training side- stepping, it is also an excellent activity for both hip strengthening and stance stability. A side step involves open kinetic chain abduction and placement of the dynamic limb to the side and closed kinetic chain abduction (stability) on the stance limb. Once the dynamic limb is placed on the ground with appropriate weight shifting and weight acceptance, the remaining limb is then moved parallel to the first (“Step together”). Abductors are active on both the dynamic limb (to move the limb) and the static limb (to keep the pelvis level). Side-stepping has important functional implications for movement in confined or crowded areas or working at an elevated surface (e.g., kitchen countertop). However, the energy requirements are comparatively high and should be considered in treatment planning. Walking, side-stepping Specific gait training according to each problem: If the patient has a problem in swing phase, the therapist can ask the patient to cross obstacles in parallel bar while a weighted cuff is put around the ankle. Also, if the patient are not able to stand over affected limb (single limb support), side walking in parallel bar toward affected side can help in addition to side stepping over a small box. Loss of initial contact can be managed by exercises that stress the ankle dorsi-flexors or using bandage wrapping that tie the foot to the shank of tibia. Leaf spring AFO can be used if calf flexibility is existed and weakness of tibialis anterior is irreversible. If the patient walks with knee recurvatum, the flexibility of calf has to be checked in addition to strengthening of knee extensors by forward stepping over a small box, see table below. Body Weight Supported Treadmill Training Body Weigh Supported Treadmill Training (BWSTT) involves the use of a suspension system with harness over a treadmill for gait training. The person with stroke is secured in the harness for fall prevention, then is positioned over the treadmill and attached to the suspension system. Gait training with this modality allows for more control over the ambulation environment (level surfaces, grade of surface), control over the speed of ambulation, and allows one or more therapists to provide tactile cues or physical assist to achieve gait dynamics. The person can be unweighted by the suspension system, this reduces the amount of weight bearing through their lower limbs and gives the feeling of being lighter. Ambulation will therefore require less effort by the person during initial gait training sessions. Body weight can be slowly added back to the person's control as they progress through their BWSTT program. Skilled therapists can assist with limb advancement, heel strike, stance with knee control, and swing phases of gait with tactile cues. Upright posture can also be addressed with this treatment modality. Functional Electrical Stimulation Functional Electrical Stimulation (FES) is a useful modality for rehabilitation after stroke, and can supplement NMR and strengthening interventions. FES is used to elicit action potentials in the peripheral nerves of axonal branches and generate muscle contractions via surface electrodes placed over a muscle group. The intensity of contraction can be controlled by adjusting the amount of stimulus given by the FES machine. Use of this modality requires a strong understanding of anatomy for proper electrode placement. FES has been used in rehabilitation of chronic hemiplegia since the 1960s. FES can be performed using a small handheld unit, a wearable unit, or integrated into a upper or lower extremity bicycle. Robotic-Assisted Training Stroke rehab requires hundreds of thousands of repetitions of a movement to cause permanent changes in the brain. New technology in the form of robotics can assist in achieving these numbers. Robotic devices provide safe, intensive and task- oriented rehabilitation to people with mild to severe neurologic injury. It provides: precisely controllable assistance or resistance during movements, good repeatability, objective and quantifiable measures of subject performance, and increased training motivation through the use of interactive biofeedback. Robotic- assisted training reduces the amount of physical assistance required to walk reducing health care costs, provides kinematic and kinetic data to control and quantify the intensity of practice, and measures changes and assess motor impairments with better sensitivity and reliability than standard clinical scales. Management of Specific problems: Shoulder pain: It may be caused by frozen shoulder, shoulder impingement, and complex regional pain syndrome. Frozen shoulder: it mainly caused by immobility and follows the capsular pattern (Limitation of external rotation, followed by abduction, and internal rotation). Management: Hot packs, ultra-sound, gleno-humeral joint mobilizaion (Gliding), capsular stratching exercises, active and active assisted shoulder ROM exercises, Facilitation and active exercises for rotator cuff, shoulder flexors , abductors and para-scapular muscles to restore the normal active scapulo-humeral rhythm. Failure of conservative management maynecessitate manipulation under anesthesia or capsulotomy. Shoulder impingement: Inflammation of supraspinatus tendon is caused by: - Limited scapular mobility because of tight and/or weak para-scapular muscles - Weakness of rotator cuff mainly external rotators - Tightness of posterior and inferior parts of the capsule - Tightness of pectoralis major and minor - Loss of normal scapulo-humeral rhythm. Management: - Facilitation and resistance for serratus anterior muscle and upper fibers of trapezius muscle to restore the scapular upward rotation - Faciliation of middle, lower fibers trapezius muscle in addition to rhomboids to assist in the function of rotator cuff as rotator cuff will not perform their normal function without good fixation of scapula because the difference in the weight between the scapula and upper limb. - Facilitation and resistance for supra-spinatus muscle (1st 30 degrees of abduction) as tendon will never heal without gradual loading. - Stretching for pectoralis minor and major to correct anterior tipping position of the scapula - Restore the normal flexibility of the capsule by inferior and posterior mobilization Complex regional pain syndrome (Type 1): Complex regional pain syndrome (CRPS) is a form of chronic pain that usually affects an arm. complex regional pain syndrome (CRPS) typically develops after a fracture, a surgery, a stroke or a heart attack. The pain is out of proportion to the severity of the initial injury. Symptoms: Hand swelling, finger stiffness, loss of hair, brittle nails, abnormal vasomotor changes (hotness, coldness), abnormal sweating, osteoporosis, hyperesthesia, Continuous burning or throbbing pain, and shoulder stiffness. Complications If CRPS isn't diagnosed and treated early, the disease may progress to more- disabling signs and symptoms. Tissue wasting (atrophy). The skin, bones and muscles may begin to deteriorate and weaken if you avoid or have trouble moving an arm because of pain or stiffness. Muscle tightening (contracture). You also may experience tightening of the muscles. This may lead to a condition in which the hand and fingers or contract into a fixed position. Prevention These steps might help you reduce the risk of developing CRPS: Early mobilization after a stroke. Some research suggests that people who get out of bed and walk around soon after a stroke (early mobilization) reduce their risk of developing CRPS. Management: - Weight bearing exercises - Proprioception training for shoulder, wrist and fingers: Chronic pain convert Proprioceptors to pain receptors so every normal movement perceived as a painful motion -TENS - Mirror therapy - Edema reduction by elevation and wrapping - Shoulder, fingers, and wrist mobilization exercises and active assisted exercises to restore the passive and active ROM. - Encourage bilateral upper limb activities. Failure of conservative management may require referral for pain clinic. Recent researches for Dysphagia after stroke: In about 40% of stroke survivors dysphagia is persistent. Patients with dysphagia have an increased risk for pneumonia which is probably linked with the severity of dysphagia since the risk is even much greater in patients with aspiration. As to frequency, brain stem lesions more often cause dysphagia compared to hemispheric strokes. Combined lesions have the highest risk for developing oropharyngeal dysphagia. Management: - Expiratory muscle strength training - Respiratory muscle strength training - Tongue stretching exercises - Tongue-to-palate-resistance-training - Jaw opening exercise - Chin tuck against resistance exercise - McNeill Dysphagia Therapy - Neuromuscular electrical stimulation of supra-hyoid and infra-hyoid muscles - Faucial pillar stimulation: Cryotherapy - Sensory-level electric stimulation of masseter - Transcranial direct current stimulatiuon (tDCS) - Repetitive Transcranial magnetic stimulation (rTMS) Recent researches for Orthosis description to enhance transfer and walking after stroke: KAFO and AFO are the most common orthotic devices involving the knee and ankle joints. The KAFO is used in hemiplegic patients with unstable knee and ankle joints. It can support, stabilize, and limit the movement of the joints and is suitable for knee and ankle joints rehabilitation. Of course, there is also a knee orthosis (KO) for simple knee joint stabilization. AFO is widely used for foot, ankle deformities, and foot drop. KAFO gait requires upper limb muscle strength, increases gait fatigue and may lead to upper limb musculoskeletal injury. Consequently, the KAFO is often used for standing posture or gait training rather than functional gait. However, some studies have shown that KAFO may positively affect patient recovery. A previous study showed that using a KAFO early could significantly improve the ADL in stroke patients. Another study showed that in hemiplegic patients, the adjustable posterior strut KAFO was more suitable for patients with better motor function, whereas traditional KAFO was suitable for patients with severe symptoms and difficulty obtaining practical walking ability. Upper limb rehabilitation: Task-oriented approach: Requirements for reaching activity and hand drawing over a board: 1- Trunk stability: achievement of stable trunk in spite of mobile upper limb 2- Shoulder, elbow, wrist stability: Holding the shoulder in flexion position requires sufficient power of para- scapular muscles, PROM, and isometric exercises of shoulder flexors. Fixation of elbow extension can be improved by weight bearing activities with dual-task where extra-pyramidal system dominate, allowing pyramidal tract to manipulate the hand Wrist extension can be maintained by inhibition of flexor spasticity and tightness in addition to isometric exercises for wrist extensors. 3- Grasping and release: Finger extension and flexion can be facilitated by dorsal splint over the wrist (shorten flexors and lengthen the extensors) or Functional NMES for wrist extensors 4- Thumb and finger manipulation: tip to tip prehension , pad to pad prehension, and thumb opposition. Assistive devices may be used. Constraint-induced movement therapy (or CIMT) is frequently used as a therapy to re-learn to use the affected upper limb. Constraint-induced movement therapy basically means limiting the use of the less affected limb in order to force the brain and more affected limb to work together. Active wrist extension in addition to some degree of finger extension in paretic hand is required before any engagement in this therapy. Reference O'Sullivan, S. B., Schmitz, T. J., & Fulk, G. (2024). Physical rehabilitation, 8th Edition, FA Davis, p 667-678. Improving Functional Outcomes in Physical Rehabilitation, 2e Eds. Susan B. O’Sullivan, and Thomas J. Schmitz. McGraw-Hill Education, 2016 Introduction to the "The Bobath Approach for Adults with Neurological Disorders  Bobath Concept Practice The Bobath concept is an inclusive, individualized therapeutic approach to optimize movement recovery and potential for persons with neurological pathophysiology (Michielsen et al. 2017, Vaughan- Graham et al. 2019) Facilitation is a Bobath clinical skill. This facilitation is an active process (based on the interaction between therapist and patient) that seeks to influence sensory information through specific handling using the key point of control (KPC), environmental and verbal cues. The patient’s response to facilitation informs the clinical reasoning process (Michielsen et al. 2017, Vaughan- Graham et al. 2019,). What are KPC? KPC are parts of the body where the therapist can most effectively control, change and /or modify; tone, patterns of posture and movement in other body parts, and goal and function. Central: Thorax Proximal (PKPC): shoulder/scapula, pelvis/hip Distal (DKPC): hand and feet. Bobath is a problem-solving approach to the assessment and treatment of individuals with disturbance of function, movement and postural control due to lesion of the central nervous system (IBITA Education committee, 2008). Assessment In the assessment of a patient, it is essential to consider:  Alignment of trunk and head.  Postural control / balance and stability.  Alignment of both muscles and joints.  Muscle length and its influence on flexibility and force production (length tension relationship).  Proprioceptive input and how this influence patient feedback mechanism.   Level of patient activity and functional potential.  Analysis of patient movement and compensation strategies. Acute/sub-acute stage Flaccidity may be:  A response to shock but not representative of damage  A brief / transitory phase  Is not seen in all patients (based on the cause of stroke).  In the presence of flaccidity it is difficult to elicit a response from the neuromuscular system to either maintain a posture or follow a movement. There is lack of balance reactions on both sides, inability to maintain head control, perceptual deficits and midline disorientation and generalized reduction in the CNS responses affecting level of arousal, attention and motivation (BBTA 2008). It is important not to wait for recovery but to facilitate the patient to access their potential. Treatment guides appropriate plastic adaptation and maximizes efficiency of functional movement (BBTA, 2016). Recovery that continues beyond four weeks has been attributed to plasticity, a reorganisation of the brain in which functions previously performed by the ischaemic area are assumed by other ipsilateral or contralateral brain areas (Green-Joseph, 2003). Aims of treatment during acute/sub-acute are to: 1. Create tone through achievement of a postural alignment from which movement can take place. 2. Re-access core stability. 3. Facilitate appropriate antigravity activity.  4. Restore balance mechanisms. 5. Facilitate awareness of midline through movement to and from midline. 6. Maintain mobility and viability of key points. 7. Minimize unnecessary compensation. 8. Maintain muscle viability, length and potential force. Therapists handling during acute stage should be consistent in order to:  Minimize compensation.  Prevent trauma.  Prevent fear.  Activate the patient so that they can participate as appropriate. Treatment of acute stage-Bobath Concept: During this stage, treatment works through the application of an appropriate modality of sensory and proprioceptive information relevant to function. Therapists manipulate afferent information from the periphery to influence movement control. This can be achieved through the following: 1- Appropriate Positioning Positioning is an important part of practice and is individual to each patient. There is however a danger in the acute/subacute patient of waiting for recovery of movement and relying totally on proper positioning to promote function and optimal recovery (figure 1). It is forbidden to carry the hemiplegic arm during handling the patient. Fig(1 ):Appropriate use of pillows providing trunk stability and support of the hemiplegic upper limb, and neutral alignment of the head and neck. 2- Rolling or turning in bed is taught to the patient to promote independent bilateral movement and righting reactions. 3- Improving postural stability through closed kinematic chain activity as in bridging…et (figure 2). Figure (2) Bridging exercises: provide proprioceptive input through closed kinematic chain. 4- Providing sensory input and weight shifting (figure 3) Figure 3: Sensory input to lower extremity. 5-Appropriate seating (figures 4a, 4b) Importance of appropriate seating during acute stage:  Reinforce correct alignment of the trunk and different body segments thus improve orientation to midline orientation and to environment.  Allow developing postural activity and thus minimize developing of fixation strategies and facilitate activity.  Allow for movement in the chair and away from the chair. It is also important however to consider how long a patient can sit out. Sitting for long time with hypotonic patients makes the weak body compensate for a lack of postural stability and develop fixation strategies that prevent the ability to do selective movement later. Figure (4a): Use of towel under right pelvis and thigh, and pillow support to Figure(4b ):Activation of postural right upper limb (UL) to improve control from appropriate seating trunk activity. Left UL is now more appropriately used to support weak position. trunk. De-weighting the heavy right UL onto a plinth and closing in the perceptual and physical environment enable more linear extension to be gained and a freer head for movement. Therapist provides proprioceptive and sensory input to facilitate the exploration of postural and movement control within an improved alignment and interaction with BOS. 6- Transfers The choice of lifting the patient versus active participation in the transfer will be dictated by:  Risk assessment.  Adaptability of postural tone  Alignment of body parts in sitting and seating potential.  Ability to access feed forward anticipatory postural control mechanisms.   The skill of the handler (therapists and/or care givers)  The environment.  Patient compliance. 7- Standing is essential to facilitate extension and perceptual experience about the midline with providing safety, support and protection to different body parts and joints. 8- Early facilitation of walking can be applied as an important factor in the development of balance with providing safety, support and protection to different body parts and joints. Chronic stage Aims of treatment:  Improve the level of postural stability/balance.  Maintain body schema (perception).  Alter biomechanical changes in the muscles through improving its flexibility and realigning its fibers.  Facilitate selective movement control through specific handling and improve efficiency of movement.  Improve the functional level and modify effort required by changing task or environmental modification.  Patient and family education to minimize compensation. We can influence the muscle hypersensitivity response through:  Providing proper alignment.  Establishing postural control.  Proper handling skills to facilitate selective movement control. Examples of movement facilitation that can be applied during the chronic stage according to patients problems: I - Full inhibition of flexor hypertonicity in the arm from supine: a b c d Full inhibition of flexor hypertonicity in the arm (left hemiplegia) a, the therapist first inhibits spasticity in the trunk b, mobilizing the scapula with the head of humerus supported c ,the extended arm is moved into full elevation with external rotation d, inhibiting flexor spasticity in the hand , the therapist thump on the dorsum of the wrist gives counter pressure.the arm is taken into abduction at an angle of 90 degrees to the bodyThe bobath concept is used according to the patient needs. II -Inhibiting Hypertonicity In The Arm : a b B x Inhibiting hypertonicity in the arm by moving the body proximally against the distal spastic components (left hemiplegia) a, with arm extended and his arm flat on the table behind him, the patient moves from side to side. b, with the hemiplegic arm supported beside him in extension. the patient bring his weight towards the arm, the scapula elevates and the hand remains extended. III - Inhibition of the knee extension with the hip in extension: a b Inhibition of knee extension with the hip extended: a, the therapist also inhibits planter flexion of the ankle , she avoid touching the ball of the foot as this stimulate extensor spasticity (right hemiplegia). After inhibition b , selective flexion to bring the leg back onto the bed. The arm remains at the patient side without pulling into flexion(right hemiplegia) IV - Facilitation of upright standing posture. The main requirements are: 1. Providing proper postural control and midline orientation through working on central key point (trunk) as mentioned during bridging and proper seating additionally activating the trunk in upright position 2. Proximal stability at pelvis and hips: using the pelvis as proximal key point (fig 6). 3. Knee stability: selective activation of knee extension (fig 6). 4. Stability provided distally by ankle and foot: selective facilitation of ankle and foot (fig 5 ) Fig (5 ) selective facilitation of tricpes surae with eccentric activation of soleus muscle to improve foot -ground interaction as preparation to standing and walking. Fig (6 ) Improving linear extension in standing and mid line orientation. The therapist facilitates extension using the pelvis & hips as proximal key points of control in standing. In this exercise, the patient perform semi –squat to control knee eccentrically then concentrically when returns to full extension. V- Improving the UL function during chronic stage: 1- Proper realignment at shoulder girdle that allows stability and mobility (fig 7). 2- Active UL elevation away from body with controlling alignment (fig 8).  Figure (7 ) realigning scapula from sidelying. Figure (8): Picture on the left, shows assessment of scacpular alignment ad enhancing scapular awareness. Providing proper alignment, scapular mobility then selective activation of scapular retraction. Pictures on the right show using the hand as distal key point to control the upper extremity additionally facilitation triceps to provide elbow extension. Using the upper limbs improves trunk erection and weight shifting on pelvis and LL as well.  Case study (1) Bobath concept in managing body orientation during the acute stage A case study of one patient with stroke is discussed in the following text. The patient is presented with poor vertical body orientation, sitting imbalance and potentially poor discharge outcome. Assessment and treatment of sitting balance are applied using key elements of sitting balance and postural control. Patient history Mrs Z, a 69-year-old female, was admitted to MMC on 17th February 2014 with right limb weakness, left sided nystagmus, left facial droop, dysarthria, dizziness and vomiting. She was previously fit and well, living with her husband, and working as a psychiatrist. A computed tomography scan and magnetic resonance imaging confirmed a left mid-basilar artery thrombosis with cerebellar, pons and anterior proximal medullary infarct. Figure three shows part of the MRI imaging and report. The infarct was further complicated by the patient’s history of asthma, as she developed respiratory distress and hypertension, resulting in an eight-day intensive care unit (ICU) admission. Mrs Z had a dense right hemiplegia with reduced sensation, but no cognitive or concentration deficits and no neglect evident. She had moderate dysarthria and dysphasia. Due to haemodynamic instability, medical orders stated the patient was to remain rest in bed so functional assessment was limited. During her ICU admission, the focus was predominantly on cardiorespiratory physiotherapy and her impairments and functional status remained unchanged. Physiotherapy in ICU had a strong focus on respiratory status, repositioned in bed, vertical orientation and sitting balance, ROM, and muscle flexibility. Assessment and treatment in sitting should include electing anticipatory postural adjustments, facilitating normal lengthening and shortening of trunk side flexors (proper weight shifting and righting reaction), reinforcing graded trunk extension and encouraging selective activity of abdominal muscles (Davies, 1990). Subsequently, a physiotherapy assessment of sitting balance must focus on quality of movement and posture.  Mrs Z required moderate assistance of two persons to lie to sit and moderate assistance of one person to maintain sitting balance on a pressure care mattress (fig 9). Figure 9: It show poor head and trunk control during sitting. Approach includes:  Active lie to sit  Foot mobilization and activation; with proprioceptive input from the legs and ankles, somatosensory stimulation from foot contact with the support surface plays an important role in maintaining an upright posture (Fig 10).  The upper limb was guided and facilitated through activation at shoulder , elbow and hand levels (fig 11).  With contextual hand orientation, increased dissociation between the trunk and shoulder complex around a central key point was available and allowed for  facilitation of lumbar and thoracic extension. Weight shifting and bearing on ULs are provided (fig 12 a, b).  Antigravity /postural muscles activation (fig 13).  Reaching was trialled to further encourage truncal extension. A second therapist encouraging anterior pelvic tilt and symmetry would have allowed for further thoracic extension, lumbar extension and increased ease of upper limb movement. Contaxtual hand orientated response prevented perturbation of the left upper limb and displacement of postural control. This allowed for active thoracic extension on the right.  As sitting trunk control improves; sit to stand exercise is performed with moderate assist of two therapist. In addition, reaching is practiced to gain more trunk extensor activation during standing (Fig 14 ). Figure 12 a: Figure 11: upper limb activation of Figure 10: foot facilitation and hand postural muscles activation. orientation. while providing stability at both shoulder and hand levels.  Figure 13 :reaching with the Figure 12b: activation of unaffected side to enhance trunk (thoracic and lumber) postural muscles and trunk while providing stability at both shoulder and hand extension. levels. Fig 14: sit to stand facilitation and Reaching in standing to facilitate the antigravity muscles.   After two weeks of successive treatment, the patient is able to sit independently with better head and trunk contro.l In addition to improvements on the above sitting balance, the visual observation below demonstrate Mrs Z’s impressive change over the 14 day period.(Fig 15a &b) Fig 15a: before therapy Fig 15b: after therapy References - Bobath, B.(1990) : Adult Hemiplegia. Evaluation and treatment, 3 rd ed. Oxford:Heinemann Medical Books. Shumway-Cook, A, Woollacott, M. (2007). Motor Control: Translating Research into Clinical Practice. Third Edition. Williams and Wilkins, USA. - Sue Raine, Linzi Meadows,Mary Lynch-Ellerington ,(2009).Bobath Concept Theory and Clinical practice in neurological rehabilitation. - www.bobath.org.uk - http://www.ibita.org/ - www.ndta.org - www.who.int - www.sandta.org.za - World Health Organisation (2001). International classification of functioning, disability and health. Geneva, WHO. - Gjelsvik B.E. (2008). The Bobath concept in adult neurology. Stuttgart, Germany.Thieme. - Gjelsvik B.E. (2016). The Bobath concept in adult neurology. Stuttgart, Germany.Thieme, 2nd Ed. Management of Stroke according to Brunstromm approach  Brunstromm technique -- Def. technique used subcortical motion as bridge to reach normal Voluntary controlled Movement. Subcortical Motions:. * Primitive reflexes, synergy, proprioceptive and exteroceptive stimulations) 1) Synergy It is defined as cooperative group of muscles action to produce pattern of movement either flexion or extension (s). Synergy stereotyped pattern movement of the limb. 1) Synergy UL Flexor synergy Extensor synergy Scapula Retraction and Scapula Fixed in protraction elevation Shoulder Abduction, external Shoulder extension, Rotation adduction internal rotation Elbow flexion in acute angle Elbow extension Radioulnar Supination Radioulnar pronation Wrist Variable (Common in Wrist Extension flexion)  Fingers Fisted Fingers Fisted Strong Elbow flexions Strong adduction component component internal rotation, forearm pronation Week abduction, external week Elbow extension component Rotation component Nb Neither extension of fingers in both Flexor, Extensor synergy. Flexor synergy assessment (Resistance of elbow flexion on non- affected side, use of ATNR look head to other side). Voluntary (put your hand behind your ear). Extensor synergy assessment appear as associated reaction by Resistance to a push on normal side with rotation of head toward Same side. NB: Why the extensor synergy is the dominant in the lower limb? 1) Because of release of positive supporting reaction. 2) spastic muscles are strong muscles. 3) Contact of the foot with the ground which stimulate ++ Calf muscles leading to activation of the extensor Synergy. LL Flexor synergy Extensor synergy Hip J Flex, Abd, Hip J Extension with Ext. retracted pelvis, adduction and internal rotation rotation Knee J Flexion Knee J Extension Ankle J Dorsiflexion Ankle J Plantarflexion Subtalar J Inversion Subtalar J Inversion Toes Extension Toes Flexion (dorsiflexion) (Plantarflexion) Strong Hip flexion Strong Hip adduction internal component component rotation-Knee extension and ankle planter flexion Week Hip abduction, week Elbow extension component external Rotation, component knee flexion and ankle dorsiflexion 2. (Reflexes) Primitive reflexes 1- Tonic neck reflex (by position movement of the head) a) Symmetric tonic neck reflex. Flexion of the head. Increase flex tone in UL and extensor tone in the LL. Extension of the head Increase Ext tone in the UL and Flex tone in the LL. b) Asymmetrical tonic neck reflex Rotation of the head to one side / side bending to side Increase Flex tone of the UL&LL of the occipital side (skull limb). Increase Ext tone of UL&LL of the face side (Jaw limb) c) Tonic labyrinthine supine Increase extensor Tone in body d) Tonic labyrinthine prone Increase flexor tone in body  e) Tonic lumbar reflex Similar to subject throwing ball Fix lower trunk with movement of upper trunk toward Left side (Resulting in ++ flex tone of left UL& ++Ext tone of left LL, ++ flex tone of Rt LL & ++ Ext tone of Rt UL). A) Positive supporting reaction Stimulus (Sole touch ground) – Response (Increase extensor tone in LL). N.B (normally in child up to 8 months). B) Negative supporting reaction (Normally it presents) Stimulus (Sole touch ground) – Response (Increase flexor tone in LL, hip and knee flex). Normal C) Thumb tonic reflex (Abduction of the thumb) Pathological reflex Stimulus: elevation of pronated forearm, Pressure on Common extensor origin & make gliding on radial side of forearm. Response: Extension & abduction of the thumb 3) Associated reactions Def: Involuntary limb movement of the limb which are observed due to reflexive tension of the muscle (as in hemiplegia) They are automatic movement which fixes or alter Posture e part or parts brought of parts of boy when some other parts brought into action either by (Voluntary effort) or (reflex stimulation). - Assessing associated reactions 1- Reinforcement by Yawning (inhalation phase increase flexor synergy) (Exhalation phase increase extensor synergy) * Coughing & Sneezing (evoke short periods with sudden muscle contraction). 2- Mirroring of UL  - (If we resist move of the non-affected produce the same move on the affected side) - If we resisted flexion of the non-affected side produce flexion on the affected side and the reverse. 1- Mirroring of LL (Reverse mirroring) (If we resist move of the non-affected produce the opposite move on the affected side& flexion of the non-affected produce extension on the affected side) 2- homo-Lateral limb Synkinesis - Resistance of component of the flexor synergy of the UL produce flexor Synergy of the LL. - Resist elbow flexor increases increases flexor tone in LL. 5) Raimiste’s phenomena. (Abduction & add. Phenomena) 1) supine position 2) arm crossed over the chest 3) P T stands beside non affected limb 4) Give max Resistance to non-affected side. - (Resist abduction on the non-affected side produce abduction on the affected side) - (Resist adduction on the non-affected side produce adduction and internal rotation of the hip on the affected side) NB: Hip internal rotation that is associated with hip adduction differentiate between organic and hysterical hemiplegia. NB adduction easy than abduction adduction associated with into Rotation hip NB Marie foix classify abduction & add. Phenomena as a "Co-ordination synkinesis. 4 Hand reactions NB: Hand functions included (hand grip, dexterity and hand Reactions)..... Hand reactions 1- Proprioceptive traction response (proximal traction R) - (Stretch flexor ms of one Joint of UL (any joint) --facilitate contraction of flexor ms of all other Joint leading to total shortening of the limb. 2- True grasp reflex - A) Stimulus (moving his body with deep pressure over contain area of palmer surface of hands digits). - Response (flexion MCP&IP joints). NB Weak at thumb a. B) Stimulus ++ between any 2 digits in. Palmar-dorsal direction b. Response adduction of neighboring joints. (3) Instinctive grasp reaction Stimulus: stationary Stimulus, inside Palme (ex Pencil, ball 2 fingers) grasp reflex (Moving stimulus) Response (hand close over object& PT unable to release object). -N. B. if nothing in hand (can open and close hand). Normally appears at birth, if present in adult indicate brain damage). Lesion in frontal lobe. 4) Instructive avoiding reaction Lesion in Parietal lobe. Stimulus (PT arm elevated Pronated (Palm down). – Sitting or  standing (thumb & finger extended) - Scratch on palmar aspect of hand. (Center of Palmar hand fingers" - Response exaggerated ext of fingers (over ext phenomena) (Voiding) Common in C.P 5) Souque’s Phenomena Stimulus (elevation of arm above 90 degrees forward flexion Response (hand opening "extensions) Not in all pts (5) Recovery stages General stages: 1st flaccidity. 2nd. Synergy, or tone develop (basic limb synergy developed) 3rd Voluntary Control over Synergy. (Marked spasticity). 4th Movement deviated from Synergy (Decrease spasticity). 5th. Waning of spasticity - independence from basic Synergy) 6th (Minimal spasticity) Isolated joint movement with near normal co- ordination. (a) Shoulder&Elbow 1- Flaccidity. Heavy limb sense during passive movement & No move can be elicited. 2- Basic limb Synergy or Component it will appear - No voluntary move can be imitated. - Spasticity appeared but not marking - Synergy develops (flexor before ext). - weak associated reaction & or slight increase muscle tone. 3- Voluntary control over synergy:  a. Max. spasticity b. PT take long time in this stage c. Burnstorm begin her treatment from this stage d. Marked appearance of associated reactions and ASTR 4- Some move deviated from Synergy (Decrease spasticity) a) hand behind sacrum ++ teres major & Rhomboids Major & minor & latissimus dorsi, pectoralis major. b) supination & pronation 90 elbow flexion Bilaterally c) Raising hand forward (forward horizontal position) (Shoulder flex 90 degrees) 5- Waning of spasticity (independence from basic Synergy) a) Side ward horizontal move (abduction 90 degrees). Combination between flexor (abdication &retraction scapula) and extension (ext elbow & pronation). b) Alternate supination & pronation from ext. elbow c) Arm raising forward overhead (arm forward above 90 deg) (wrist & forearm in mid position). 6- Minimal spasticity (isolated Joint Move freely) - Performed with near normal co-ordination. - basic isolated voluntary joint Move (nearly normal). - No spasticity during passive move. - spasticity appear during running B) Stages of hand 1) flaccid 2) minimal finger flexion 3) Mass flexion (hock grasp) No release Lille or no voluntary wrist extension 4) Lateral Prehension and release by thumb - Semi voluntary wrist extension. 5) Palmar prehension) (Cylindrical grasp & cylindrical grasp Controlled voluntary wrist extension 6) Isolated finger movement (all) - all other types of prehensions C) Lower limb 1) Flaccidity. 2) Minimal voluntary of L.L Spasticity develop Synergy appear 3) Mass flexion: (hip knee flexion, ankle dorsiflexion) from siting & standing. 4) From sitting (knee flexion beyond 90 degrees, Ankle dorsiflexion with heal contact on the ground (slide knee backward) 5) From standing (isolated knee flexion from hip ext, dorsiflexion from extended knee (Leg in short step standing position). 6) From standing Hip abduction. From Siting (Hip internal & ext. rotation). Muscle tone assessment (Speed test). Arm ass of spasticity - Require ROM and some degree of motor control - From 4-6 stages only  Flexor synergy PT sitting hand in lap (ulnar border near groin) have hand from lap to mouth hand in mid position (neither supinated on pronated) chin bet thumb, index a) Ext. synergy - Hand from lap to opposite knee - Pronated forearm. - Precautions (Sitting without learning forward, sitting with supported chair) - Equipment use stop watch (firstly to non-affected limb then affected limb, compare between both) ++Time ++spasticity. 7) Sensory status Concentrated on Motion Senses a) Passive motion sense for sh. Elbow, forearm, wrist). PT does with non-affected limb while PT do with affected limb Firstly, PT open eye, we move affected. Then PT repeat same. Move in same direction with eye closed (repeat again). b) Passive motion Senses for digits Hand in lap Cath from MCP joint (flexion, ext). While PT eye open demonstrate move to PT, close the eye then repeated move Then ask PT tell what the move  Aphasic patient (tell move by doing it in non-affected limb c) Fingertip recognition PT completely blind & stimulate palmer aspect tips of finger than ask.PT what finger is stimulated. d) Passive motion sense for LL as UL. e) Sole sensation: - Ass (pressure sense in foot (superficial sensation as it is important to recognize quality of walking safe. - Standing but later sitting Tech (narrow flat object (2 tongue depressor taped together). - shown to PT& ask PT without looking to determine whether or not this object has been placed a) under foot b) All way across ball of foot (side to side). c) under medical side only d) lateral side Exert Pressure ++WT. bearing Assessment (Quite place; psychologically supported, order in functional term). Principles of treatment - When move is absent, use the following: Reflexes Associated reactions Proprioceptive & exteroceptive Once voluntary Move is gained ask PT to  - do: (Eccentric, hold and concentric contraction). - If partial contro