Exercise at Office or working place

Fit to work Exercise
Bismillahirahmanirahim,

I have a lot of patient mention to me there is very hard for them to find the easiest way to do the exercise, so here I want to share what is the exercise that you can practise in the office as one of your routine.

1      Try to arrange your work to achieve a mix of sitting and moving around.

2.    Get your body moving by doing a few exercises every hour or so. This

a.    will increase circulation, send more oxygen to the brain, and help you

b.    stay alert.

3.    All the exercises should be done gently.

4.    Sit comfortably and take five slow, deep breaths before starting the exercises.

5.    Breathing should be relaxed throughout.

6.    Repeat all exercises three times.

 1. Stretch

Stand up and put the heel of your

hand into your lower back. Draw your elbows

back and down. Keeping your head and neck

steady with chin tucked in, slowly arch your

back and look to the ceiling.

         2.Forward press:

Gently interlock your

fingers. Press your palms away from your

body, gently stretching the forearm muscles,

fingers and the muscles between your

shoulder blades. Hold for five seconds

3.     Back of forearm and wrist stretch

With your elbow straight, tuck your thumb

in and make a gentle fist. Bend your wrist

forward gently stretching the forearm

muscles, wrist and fingers. Hold for five

seconds

4.     Side to Side turning

Sitting slightly forward in your seat, rotate your mid- and upper-back to the right, holding on to the backrest of the chair with your left hand. Hold for five seconds. Do the same in the opposite direction

5.     Elbow Flare

Put your hands behind your

neck, loosely grasped. Keep head and neck

tall. Squeeze below the shoulder blades

and take elbows back, taking care not to

press on the neck. Hold for five seconds

6.     Neck Turning

Rotate your head left then

right, taking care to keep your eyes on the

horizon and aiming your chin at your

shoulders. Use your eyes to focus on

something in the distance.

7.     Chin Tuck

Sitting tall, imagine you are

suspended by a piece of string from the

crown of your head. Keeping eyes level

with the horizon, tuck your chin in to make

a double chin. Hold for five seconds

8.     Shoulder Retractions

Stand or sit up straight. Pull your shoulders back behind you, squeezing shoulder blades towards each other. You should feel the stretch across

your chest. Hold for five seconds..

So hope with this guideline i created , insha Allah will give you idea how to make a move in a simplest way when you in office..

Wassalam..

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Cara mengelakkan sakit belakang dengan mudah

Postur
Bismillahirahmanirahim ...

Asalamualaikum , hari nie saya nak bawa atau kupaskan salah satu isu yang paling kerap dihadapi oleh manusia iaitu  SAKIT BELAKANG
Dianggarkan lebih daripada 80% orang dewasa pernah mengalami masalah sakit belakang dalam sejarah kehidupan mereka.

Malah, sakit belakang dan sakit tengkuk atau leher adalah kesakitan paling kerap dihidapi pesakit yang memaksa pesakit bertemu doktor pakar serta boleh  menggangu kerja atau rutin harian mereka, sakit belakang yang teruk mampu atau berkebolehan menjadi penyebab utama kecacatan, diberhentikan kerja dan membabitkan kos penjagaan dan perawatan kesihatan yang tinggi.

Secara fisiologi, leher dan bahu terdiri daripada otot, tulang, saraf, arteri dan salur darah, begitu juga ligamen dan struktur sokongan lain. Banyak keadaan yang boleh menyebabkan sakit leher dan belakang khususnya kawasan sekitar bahu. Ada yang mengancam nyawa seperti serangan jantung dan trauma serta keadaan lain seperti stress.

disini saya nyatakan Antara tabiat buruk yang boleh  menyebabkan sakit belakang:

• Individu yang berisiko adalah mereka yang gemar membongkok ke depan dan beralih ke kiri dan kanan ketika mengangkat atau menarik sesuatu.
• melakukan sesuatu pekerjaan dengan membongkok ke depan dan ke bawah ketika bekerja.
• apabila melakukan travelling dengan membawa kereta individu itu gemar perjalanan yang jauh tanpa berhenti rehat.
• pekerjaan yang memerlukan individu itu berdiri terlalu lama.
• suka atau menjadi kebiasaan membawa barang yang beratnya tidak seimbang.sebagai contoh membawa beg sandang hanya disebelah bahagian sahaja.
• Duduk membongkok di kerusi ketika menonton tv atau menggunakan komputer.
• kaum hawa yang gemar memakai kasut bertumit tinggi.

Kebanyakan masalah sakit tulang belakang ini boleh dicegah kerana ia berlaku akibat posisi mekanikal tubuh dan postur atau kedudukan yang tidak baik menyebabkan tulang belakang dibebani tekanan yang tidak normal.

Penyebab sakit belakang dan leher paling lazim bermula pada tisu lembut seperti otot, tendon dan ligamen dalam struktur ini.selalunya sakit ini berpunca apabila berlakunya kecederaan pada anggota tisu ini.

antara hidden problem seperti  perubahan tulang rawan (Arthritis ) pada spina di leher (spina cervical) boleh menyebabkan saluran laluan  mencengkam saraf dan menyebabkan leher dan bahu sakit. Cervical spondylosis dan Lumbar spondylosis pula boleh menyebabkan sakit leher dan belakang kepada kawasan setempat ataupun dipanggil localize pain  yang tidak membabitkan kawasan lain.

Setiapkali melakukan rawatan fisioterapi kepada pesakit pesakit saya , saya selalu menegaskan
agar mereka semua faham bahawa Kunci utama dalam menjaga kesihatan belakang badan dan leher adalah dengan menumpukan  kepada tiga perkara iaitu belajar mempraktikkan postur yang baik, bijak menggunakan mekanik tubuh dengan baik ketika melakukan aktiviti seharian dan kerap bersenam (amalan senaman yang sesuai).

Asas penjagaan kesihatan leher dan belakang bermula dengan postur. Ini kerana kedudukan badan yang tidak betul adalah antara penyebab masalah spina dan boleh menyebabkan kesakitan sedia ada semakin teruk. Lebih serius lagi, ia juga boleh menyebabkan kesakitan menjadi lebih kronik dan sengsara berpanjangan.

Penjagaan asas postur yang baik ialah mengekalkan kedudukan tulang belakang atau spina yang neutral iaitu memastikan tiga lengkuk semula jadinya berada pada kedudukan betul.

Tiga lengkuk itu merujuk kepada lengkuk kecil pada dasar leher, bulatan kecil di tengah bahagian belakang dan lengkuk kecil di bawah belakang badan. Spina yang neutral tidak terlalu bulat ke depan mahupun terlalu melengkung ke belakang.

antar petua untuk mengelak sakit belakang:

• Tidur di atas tilam spring; letakkan papan di atas dasar tilam.
• Elakkan diri daripada mengalami ketegangan yang boleh menyebabkan sakit belakang.
• Cuba belajar untuk kekalkan kedudukan susuk badan (posture) yang baik ketika duduk dan berdiri.
• Pastikan teknik mengankat barang dipelajari dengan betul seperti ,Apabila mengangkat barang, tegakkan belakang anda dan bengkokkan lutut saja.
• Cuba Pelajari senaman yang boleh membaiki pergerakan dan kedudukan susuk badan anda.
• Bagi mereka yang gemar memandu jarak jauh ,Jika memandu, anda perlu berhenti dan berehat seketika atau keluar dari kereta setiap 90 minit.
• Bagi wanita jika dapat cuba pakai kasut bertumit rendah.
•  Luangkan sedikit masa untuk berehat dan elakkan daripada terlalu banyak membuat kerja yang membebankan untuk jangka waktu yang lama.
• pastikan apabila memegang objek yang berat rapat ke badan anda.
• Apabila duduk di kerusi, pilihlah tempat duduk yang dapat mengampu seluruh paha anda dan biarkan kaki anda lurus ke bawah dan memijak lantai atau bangku kecil dengan selesa.

Insha Allah ini adalah serba sedikit info yang boleh anda pelajari dan fahami kerana , penjagaan tulang belakang dan posture amat penting di dalam kita mencegah daripada mendapati masalah sakit belakang.

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Tubuh yang flexible

Senaman Flexibility
Bismillahirahmanirahim,

Asalamualaikum , dalam entry kali nie saya nak share kan sedikit tentang makna flexibility yang selalu digunakan dalam kehidupan seharian kita , tetapi kita tak perasan.

Apakah yang dimaksudkan flexibility ?
Ianya merupakan satu sifat kelembutan atau pemanjangan oleh tisu tisu anggota tubuh yang mengelilingi bahagian sendi seperti Otot , Connective tisu dan Kulit .
Kelebihan mempunyai flexibility ianya akan meminimumkan kecederaan apabila tubuh badan melakukan aktiviti sukan atau lasak.

Kenapa flexibility ini amat penting ?
kerana dengan flexibility tubuh badan anda mampu dielakan daripada mengalami masalah kecederaan yang serius kerana ia membantu menyediakan otot serta tendon yang longgar sebelum melakukan apa apa aktiviti.

Ianya juga mampu mengoptimumkan fungsi penyembuhan pada tisu anda dengan mengurangkan pembentukan tisu tisu keras dan juga parut .

Bagaimana kita hendak mencapai flexibility ?
Flexibility boleh dibentuk dengan melakukan senaman rengangan yang consistant dan ianya boleh dijadikan satu aktiviti yang wajib sebelum memulakan apa jua aktiviti yang lasak seperti bersukan.

Bila senaman renggangan boleh dilakukan?
1.Sebelum dan selepas melakukan aktiviti fisikal
2.Ketika melakukan senaman pemulihan rehabilitasi dimana stretching hendaklah menjadi satu senaman ketika pemanasan dan penyejukan serta dipastikan senaman renggangan dilakukan dengan meminimumkan rasa sakit.

Bagaimana melakukan stretch?
yang pertama sekali tanya fisioterapi anda he he kerana dengan panduan yang betul ianya mampu mengelakkan senaman menjadi masalah atau mendatangkan kecederaan yang tak diundang.

Jenis senaman stretching terbahagi kepada 2
= SLOW STATIC STRETCH
senaman ini memerlukan kekuatan anggota badan yang lain atau menggunakan alat alatan bantuan seperti dumbell , meja atau kerusi ,selalunya senaman ini ditahan dalam 15 ke 30 saat .
contoh :
senaman ini mudah dilakukan dalam apa jua keadaan.

=CONTRAX RELAX METHOD
Selalunya senaman ini dilakukan dengan melakukan stretching dalam keadaan interval yang merulang ulang sebagai contoh kita stretch dengan melawan resistant dan tahan 6-8 saat kemudian berehat 2-5 saat dan dilakukan berulang kali .


So info ini sedikit sebanyak mampu menjelaskan bahawa senaman flexibility ini amat mudah dilakukan dan boleh dilakukan dalam apa jua keadaan

Wasalam...

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Urutan Kepala Triger Point (Migrain, Cluster Head , Cervical Myalgia)

Trigger point untuk sakit kepala

Bismillahirahmanirahim..

Untuk entry kali nie saya nak share kan salah satu cara untuk merawat sakit kepala yang selalunya mengakibatkan segala urusan kerja kita akan tertangguh,

rawatan yang ingin saya kongsikan ini adalah digunakan ketika kita dalam keadaan yang penat atau sakit kepala.

3 pekara kepada manusia yang kalau sakit ini datang habis segala urusan kerja  dan emosi akan berubah iaitu sakit kepala , sakit gigi dan juga sakit perut

urutan kepala ini selalunya saya ajarkan kepada pesakit saya yang mengalami masalah cervical pain dan dia akan radiate ke bahagian kepala , ada ketika dia akan mengakibatkan sakit kepala yang teramat dan menggangu kehidupan pesakit.

Teknik ini simple dan mudah dilakukan sendiri

1. Sebelum lakukan urutan minum air dengan secukupnya dan basahkan rambut atau balutkan dengan tuala lembab bagi memberikan kelegaan sejuk bagi bahagian kepala.
2. Untuk makluman dibahagian belakang tengkorak kita terdapat satu bahagian point yang amat penting didalam penyambungan otot tengkorak dengan tulang leher , dan kadang kadang area ini mungkin ketat dan mengakibatkan sakit kepala boleh terjadi.
3. 
4. Otot penyambungan ini dipanggil subbocipital group muscle .
5. Gunakan Ibu jari dan cari bahagian yang ditekan akan rasa sakit atau lesu , kesakitan yang dirasa ketika ditekan adalah tender,ada kajian menyatakan otot ini boleh menjadi penyebab kepada cluster head pain dan juga Migrain.
6. Tekan ibu jari anda kebahagian subbocipital area ini dalam 10 saat ke 15 saat , nafas secara perlahan lahan dengan menarik nafas melalui hidung dan dilepaskan secara perlahan melalui mulut.
7. Bahagian yang tender ini diurut secara circular atau bulatan , Pada permulaan akan rasa sedikit tender , tetapi apabila endorphin hormon dilepaskan kesan dari urutan ini , akan ada rasa kelegaan pada bahagian kepala nanti.
8. 
9. Cara ini adalah merupakan cara yang simple dan terbukti banyak membantu pesakit saya,oleh itu anda boleh mencubanya dan dengan izin Allah kesakitan pada bahagian kepala boleh hilang dan dikurangkan.

Wassalam...

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Teknik batuk yang berkesan membuang kahak

Effective Coughing

Bismillahirahmanirahim...
 Asalamualaikum w.b.t hari nie nak citer sikit mengenai cara atau teknik batuk untuk membuang kahak dengan betul...

Bagi pesakit pesakit yang berumur , atau anak anak kecil , mereka tidak dapat memahami apa itu cara batuk yang berkesan .

Batuk adalah satu cara semula jadi yang di ciptakan allah untuk kita mengeluarkan kahak atau benda asing yang memasuki dalam saluran udara kita . Bayangkan kita tak reti batuk apa yang akan terjadi kepada paru paru kita, semestinya peparu kita akan dipenuhi lendir yang dipanggil kahak..

Teknik batuk ini biasa diguna pakai oleh kami selaku fisioterapi, ianya memudahkan pesakit memahami bertapa pentingnya menggunakan teknik yang betul.

Melalui pengalaman saya bermacam macam karenah yang saya temui ketika mengajar pesakit pesakit saya untuk batuk , ada yang bila disuruh batuk di tak batuk tapi dia berdehem , kadang kadang ada yang batuk dia saja saja buat macam batuk kucing je bunyinya...

Cara untuk melakukan teknik batuk yang berkesan ialah.

1. ketika di waktu pagi adalah waktu yang paling sesuai untuk kita lakukan kerana waktu ini kadar kelikatan kahak amat tinggi dan pekat , maka saya cadangkan anda gunakan air panas yang dituang di dalam bekas , masukkan 5 sudu garam ,kerana stim air garam amat membantu dalam mencairkan kahak.
2. Secara perlahan hirup wap air garam melalui hidung dan hembus melalui mulut , lakukan berulang kali dalam 15 atau 20 kali hirupan , cuba bernafas dengan dalam dan biarkan nafas berhenti seketika dalam 3 saat bagi menggalakan penyerapan wap air itu kedalam peparu .
3. Cuba bersandar atau duduk dalam keadaan tegak tarik nafas melalui hidung sedalam dalam yang boleh dan hembus melalui mulut seperti menyebut huruf O, lakukan sebanyak 5 kali .
4. Pada hembusan nafas yang akhir tahan dalam 5 saat kemudian batuk dengan kuat.
5. lakukan step 3 dan 4 ini sehingga anda benar benar rasa kahak yang dikeluarkan semakin kurang.

Teknik ini amat berkesan dilakukan bagi pesakit yang mengalami masalah asthma , chronic bronchities, COPD dan juga Bagi perokok yang tegar . Wasalam...

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Cause Achilies Tendon Ruptured

Tendon Ruptures
Bismillahirahmanirrahim...

Come we learn another interesting topic ..

ACHILLES TENDON RUPTURE

What is the Achilles Tendon?

Tendon = band of tissue that connects a muscle to a bone.

Achilles tendon

a.k.a the "heel cord, 

a strong band of elastic connective tissue that runs down at the back of the lower leg

the Achilles tendon is formed from the gastrocnemius, soleus, and plantar muscles of the calf and is attached to the calcaneous (heel-bone).

largest and strongest tendon in the body.

What is an Achilles Tendon Rupture?

Partial :partly torn but still joined to the calf muscle.

Complete :completely torn so that the connection between the calf muscles and the ankle bone is lost.

Mechanism of injury : occurs when the tendon is stretched beyond its capacity such as :

• forceful jumping or pivoting
• sudden accelerations of running
• falling or tripping.
• forceful push off with the foot
• suddenly forced into an upward pointing position
• deep cut at the back of the ankle

The Achilles tendon is weak due to :

• Corticosteroid medication (prednisolone) - mainly if it is used as long-term treatment rather than a short course.
• Corticosteroid injection near the Achilles tendon.
• Older age (60 years onwards).
• Certain rare medical conditions such as Cushing's syndrome, where the body makes too much of its own corticosteroid hormones.
• 'Tendonitis' (inflammation) of the Achilles tendon.
• Other medical conditions : rheumatoid arthritis, gout and SLE (lupus).
• Certain antibiotics (quinolone).
• The risk  actually very low, and mainly applies if you are also taking corticosteroid medication or are over age 60.  

Risk factors :

Typically, middle-aged people participating in sports in their spare time.

Less commonly, illness or medications, such as steroids or certain antibiotics, may weaken the tendon and contribute to ruptures

 

Signs and Symptoms

•  Sudden sharp pain (which feels like a kick or a stab) in the back of the ankle or calf – usually settles quickly and often subsiding into a dull ache.
• A popping or snapping sensation.
• Swelling on the back of the leg between the heel and the calf.
• Difficulty walking (especially upstairs or uphill).  
• Difficulty rising up on the toes.
• Flat footed walk - can walk and bear weight, but cannot push of the ground properly on the side where the tendon is ruptured
• May feel a gap just above the back of the heel in complete tear. However, if there is bruising then the swelling may disguise the gap.

TREATMENTS

Early action that should be taken - the "R.I.C.E." method

1. Rest. Stay off the injured foot and ankle, since walking can cause pain or further damage.
2. Ice. Apply a bag of ice covered with a thin towel to reduce swelling and pain. Do not put ice directly against the skin.
3. Compression. Wrap the foot and ankle in an elastic bandage to prevent further swelling.
4. Elevation. Keep the leg elevated to reduce the swelling. It should be even with or slightly above heart level.

Decision of Rx are based on the

• severity of the rupture
• the patient’s health status
• activity level (active VS less active)‏
• individual preference and circumstances.
• Types of Rx :
• Non-Surgery
• Surgery

Both options will involve having a plaster cast or brace (orthosis) for about 8 weeks, to protect the tendon while it heals.

 The plaster or brace is positioned so that the foot is pointing slightly downwards, which takes the strain off the tendon.Traditionally, patients were given crutches to keep weight off the leg during the first few weeks of treatment.

       Now there is a trend towards 'early mobilization' involves fitting a plaster or brace which you can walk on more convenient because do not need to use crutches. Physiotherapy is often provided as well.

Non-Surgery
-a.k.a 'conservative treatment’.

-the tendon heal naturally, resting it in a brace or plaster cast.

-Generally associated with a higher rate of re-rupture

Selected for

• minor ruptures
• Older or less active patients
• those with medical conditions that prevent them from undergoing surgery

Involves use of

• Cast
• walking boot
• brace

Fx : to restrict motion and allow the torn tendon to heal.

A surgical repair can then be done later, if the tendon :

does not heal on its own and re-rupture.

Surgery
recommended for

• younger people
• those doing sports.
• delay in starting treatment.

Offers important potential benefits such as :

• Decreasing the likelihood of re-rupturing the Achilles tendon,
• Often increases the patient’s push-off strength and improves muscle function and movement of the ankle.

Various surgical techniques are available :

• type of surgery called ‘percutaneous’ -  uses smaller cuts than the traditional operation. It  reduce the risk of getting a wound infection.
• sews together the torn ends of the Achilles tendon
• may also use another tendon
• a tendon graft to help with the repair.

The surgeon will :

• select the procedure best suited to the patient.
• determine when the patient can weight bearing.
•  Following surgery, the foot and ankle are initially immobilized in a cast or walking boot.
•  after surgery, a brace seems to be better than a plaster cast in terms of faster recovery and return to normal activities, a lower complication rate and patient preferences. 

Complications such as :

• incision-healing difficulties - the tendon may scar or become shorter
• re-rupture of the tendon
• nerve pain
• wound infection
• reduced sensation near the operation site

PHYSIOTHERAPY MANAGEMENTS

ACHILLES TENDON REPAIR
REHABILITATION PROTOCOL

PHASE I (0-8 WEEKS)

WEIGHT BEARING –

i.  (0-4 weeks) :Heel toe touchdown weight bearing in post-op splint.

ii. (4-8 weeks) : As tolerated with crutches & cam walker.

BRACE –

i.  (0-2 weeks) : Worn at all times.

ii. (2-4 weeks) : Locked at 20 ° of plantarflexion – worn at all times except for exercise & hygiene.

iii.(4-8 weeks) : Worn during weight bearing activities.

ROM –

i.  (0-2 weeks) :NO physical therapy & motion

ii. (2-6 weeks) : Limit active dorsiflexion to 90° with knee flexed at 90°

iii.(6-8 weeks) : ROM to tolerance

THERAPEUTIC EXS -

i.  (0-2 weeks) : NO physical therapy & motion

ii. (2-8 weeks) : Inversion/eversion ROM, stationary bike with brace on, knee/hip strengthening, joints mobilizations – NO passive heel cord strecthing

PHASE II (8-12 WEEKS)

WEIGHT BEARING – As tolerated with crutches – discontinue crutch use when gait is normalized

BRACE – None

ROM – gain full & pain free

THERAPEUTIC EXS – Begin light dorsi/plantarflexion exs with knee flexed, inversion/eversion isometrics, cont. with bicycle & knee/hip strengthening

PHASE III (12 WEEKS - 5 MONTHS)

WEIGHT BEARING – Full with normalized gait pattern

BRACE – None

ROM – Full & pain-free

THERAPEUTIC EXS – Progress Phase II activities, begin inversion/eversion isotonics, aggressive dorsi/plantarflexion resisitive exs with emphasis on plantar eccentrics

Besides that, generally what we can do….

• Help reduce swelling and pain though application of :
• Electrotherapy such as ultrasound
• compression bandaging
• Passive exs – to increse ROM
• AROM - avoid pain when exercising
• active free exs : plantarflexion, dorsiflexion, pronation, supination, inversion and eversion
• Mobilising exs :
• Ankle Circles : Sit on the floor or in a chair. Remove shoes and socks. Moving only your ankle, draw circles. Repeat 10 to 20 times.
• Drawing The Alphabet: Sit on the floor or in a chair. Remove shoes and socks. Moving only your ankle, draw the alphabet on the floor. Do the entire alphabet once.

Stretching exercises :

Gastrocnemius

Soleus

Strengthening exercises :

Hip :SLR, hip pattern

knee : SQE, IRQ

Ankle : Resistive Tubing Exercises (Theraband)‏

                : Toe Raises

                : Walking on Heels

                : Toe Scrunch:

-Place a towel on the floor near your chair.

-Sit down, placing the toes of one foot on  the towel.

-Use your toes to scrunch up the cloth.    

Keep your heels flat on the floor.

Repeat 10 to 20 times

: Wobble Board

Postural challenge - partner challenges a person's stability while he or she is standing on one leg, gently touching the person in one direction and then the other.

Mini Trampoline Exercises -Stand on a mini trampoline with one foot. Work up to two minutes without falling, then switch to the other ankle.

Progression to :

hop and stop

throw ball

fig 8's

running

Instruct on use of crutches if needed

• NWBC
• PWBC
• Strap the ankle to make walking easier.
• Functional actvt e.g. ambulation,step up & down, running, jumping

Pt education :

• keep ball of foot supported when long sitting to avoid your ligament healing in a lengthened position. 

For sports

Advise on when to return to sport.

Start with warm-up exercises.

Recommend ankle braces

Corticosteroid medication (prednisolone)‏

Should be used carefully and the dose should be reduced if possible. But note that there are many conditions where corticosteroid medication is important or lifesaving.

Quinolone antibiotics

Should be used carefully in people over 60 or who are taking steroids. 

wallahuallam... 

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Pushing Syndrome in stroke patient

Managing Pushing syndrome after stroke
Bismillahirahmanirrahim ....

lets go for another topic that are related in stroke management , there are calling a pusher syndrome...

Abstract

• Pusher syndrome in patients post-stroke is characterized by leaning and active pushing toward the hemiplegic side with no compensation for the instability,  and resistance to passive correction toward midline.
• require longer than average to reach independence in activities of daily living and ambulation 
• present primarily in patients with right hemispheric lesions centered in the area of the posterolateral thalamus. 
• misperceive body orientation in space, 18° tilted toward the ipsilesional side
• Visual cues and cognitive strategies as potential rehabilitation tools for correction of body posture.

Patients with pusher syndrome tend to have profound functional limitation(self transfering, standing and gait.

Purpose of this review

    -characteristic of pusher syndrome in post-

     stroke pt

    -location of stroke lesion

    -cause of behavior disorder

    -discussion of physical therapy intervention

Characteristic of Patient with Pusher Syndrome

• left hemiplegia (right brain lesion)
• spatial and sensory neglect of the hemiplegic side(physical and environmental)
• postural asymmetries
• shift of body weight toward the hemi-plegic side with no attempt to support or compensate for the resultant imbalance 
• no protective responses when active pushing leads to postural instability in sitting and standing
  Therefore at high risk for falls. 
• In severe case, sensory impaired(tactile, proprioceptive, visual and auditory stimuli)
• However, all 23 of the patients with contraversive pushing in the study by Karnath et al displayed severe paresis of both the upper and lower contralesional extremities
• The severity of paresis of the hemiplegic extremities has not been shown to directly influence the presence of pushing or body orientation with respect to gravity while seated.

How to Distinguish?

• Active pushing with the nonparetic extremities : distinguish patients with pusher syndrome from patients with thalamic astasia and lateropulsion in Wallenberg's syndrome.
• When asked to sit up, patients with astasia typically grasp the side rail of the bed with the unaffected hand or with both hands and pull themselves up, rather than using the available power of the trunk.
• While patients with pusher syndrome extend the unaffected arm and using it to actively push away from the nonparetic side.
• Patients with Wallenberg’s syndrome display a tilt in subjective visual vertical but in pusher syndrome, it is intact.
• The tendency of patients with Wallenberg's syndrome is to fall sideways toward the side of the lesion, compared to patients with pusher syndrome who fall to the side opposite the lesion.
• Able to maintain correct head orientation toward vertical in the presence of severe lateral lean

• helps to differentiate patients with cerebral lesions in the posterior insula('vestibular cortex,‘),experience a perceived tilt of the subjective visual vertical

Location of Stroke Lesion.

1.  infarctions clearly centered on the posterolateral thalamus
2.  including the ventral posterior nucleus, lateral posterior nucleus(which seems to be critical in control of upright posture) .( Karnath et al,2002)
3.  In another study shows that thalamic and extra-thalamic lesion also can cause pusher syndrome
4.   Different types of imaging technology used to determine the structural damage as well as malperfused but structural intact tissue.
5. Study shows that thalamic lesions did not show a systematic involvement of dysfunctional brain areas in addition to the ones found to be structurally damage   And in extra-thalamic lesion, thalamus was neither structurally damaged nor malperfused 
6.    However, abnormality seen in these areas in extra-thalamic lesion in pusher syndrome’s patient.(inferior frontal gyrus, middle temporal gyrus, inferior parietal lobule, and parietal white matter.)
7. Thus, these extra-thalamic brain areas contribute to the network controlling upright body posture. (Luca Francesco Ticini, Uwe Klose Thomas Nägele and Hans-Otto Karnath, 2009)

Causes of Pusher Syndrome

1. results from a high-order disruption in the processing of somesthetic information originating in the contrale-sional hemibody.suspected that this could be gravi-ceptive neglect.
2. The patients perceive their body as oriented 'upright' when it is tilted an average of 18° to the ipsilesional side severe misperception of body orientation in relation to gravity
3. Pushing is a response of patients' unexpected experience of loss of lateral balance when trying to get up and sit upright in a vertically oriented room.

MEASURING CONTRAVERSIVE PUSHING
Scale for Contraversive Pushing (SCP)

3 criteria

(1) posture: symmetry of spontaneous posture while sitting and standing,

(2) extension: the use of the ipsilesional arm or leg to extend the area of physical contact to the ground while sitting and standing, and

(3) resistance: resistance to passive correction of posture while sitting and standing.

PHYSICAL THERAPY INTERVENTIONS and RECOVERY OF FUNCTION FOR PATIENTS WITH PUSHER SYNDROM

1. Some patients with pusher syndrome can 'learn' to balance in standing with their feet apart within a half-hour session.(Bohannon RW, 1996)
2. appropriate positioning over their feet, practicing and feedback to patients, they can achieve a short duration of independent static standing
3. 3 stage of practices:back against wall,without support, during movement .
4. Karnath et al, 2000 and Perennou, 2002 noted that patients able to align body axis with the use of visual cues from environment.
5. Using the upright orientation of surrounding objects and persons.
6. However, it is temporary. Thus, visual input alone not suffice to continuously control upright posture.
7. It may be an effective training tool when combined with conscious strategies for postural control.
8. It is believed that applying TENS by activating various afferent nerve fibers in the neck
   convey stimuli to the contralateral cerebral hemisphere, unmasking the patients' latent postural capabilities.
9. TENS as substitution stimulus to reactivates the damaged neural network devoted to body orientation with respect to gravity.
    and lower initial activities of daily living (ADL) function scores as measured by the Barthel Index
10. subjects with pusher syndrome had more severe strokes as expressed by lower neurological scores on the Scandinavian Stroke Scale
11. According to Pedersen and colleagues(1996), pushing should first diminish in the supine position, then in the sitting position, and finally in the standing position.However, no supportive evidence.
12. Pusher syndrome was found to slow the recovery process post-stroke,requiring an average of 3.6 weeks (63%) longer to reach highest ADL function

Conclusion

•  patients with pusher syndrome display a misperception of body orientation in space, believing that the upright position is approximately 18° tilted toward the ipsilesional side.
• suspected that is the result of 'graviceptive neglect' of signals originating in the contralesional trunk and pelvis
• Pushing may be an attempt to compensate for a mismatch between an intact perception of the visual vertical and an impaired perception of postural vertical
• Visual cues and cognitive strategies can be rehabilitation tool
• Slow recovery process has been found in patient with pusher syndrome
• Longer than average to reach independence ADL and ambulation

Wallahuallam...

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