special subjects
Stroke Rehabilitation
Ambulation problems
Before ambulation exercises can be started, patients must be able to stand. Patients first learn to stand from the sitting position. The height of the seat may need to be adjusted. Patients must stand with the hips and knees fully extended, leaning slightly forward and toward the unaffected side. Using the parallel bars is the safest way to practice standing. The goal of ambulation exercises is to establish and maintain a safe gait, not to restore a normal gait. Most patients with Hemiplegia have a gait abnormality, which is caused by many factors (eg, muscle weakness, spasticity, distorted body image) and is thus difficult to correct. Also, attempts to correct gait often increase spasticity, may result in muscle fatigue, and may increase the already high risk of falls. During ambulation exercises, patients place the feet>15 cm (> 6 inches) apart and grasp the parallel bars with the unaffected hand. Patients take a shorter step with the hemiplegic leg and a longer step with the unaffected leg. Patients who begin walking without the parallel bars may need physical assistance from and later close supervision by the therapist. Generally, patients use a cane or walker when first walking without the parallel bars. The diameter of the cane handle should be large enough to accommodate an arthritic hand. For stair-climbing, ascent starts with the better leg, and descent starts with the affected leg (good leads up; bad leads down). The muscle groups of the better leg are stronger than the affected leg and can better control the ascent (with concentric contractions) and the descent (with eccentric contractions). Additionally, this technique minimizes the affected leg's hip and knee range-of-motion needed for stair-climbing. If possible, patients ascend and descend with the railing on the unaffected side, so that they can grasp the railing. Looking up the staircase may cause vertigo and should be avoided. During descent, patients should use a cane. The cane should be moved to the lower step shortly before descending with the bad leg. Patients must learn to prevent Falls in Older Adults , which are the most common accident among For patients with symptomatic Orthostatic Hypotension , treatment includes support stockings, medications, and tilt table training. Because hemiplegic patients are prone to vertigo, they should change body position slowly and take a moment after standing to establish equilibrium before walking. Comfortable, supportive shoes with rubber soles and with heels≤2 cm (3/4 inches) should be worn. 