walking with your hands

I have been treating a patient with an acute (L) CVA for two weeks now. His main impairments have been an inability to walk without two mod-max assist, a flaccid upper limb, expressive aphasia and a two assist transfer. We have focused on his poor hip mobility and ankle range to progress to walking. Recently he has progressed to a one mod and one min assist with a quad cane or parallel bars, for about 6 steps. He fatigues so quickly and becomes emotional, so our sessions are quite exhausting and yet both physios and patient are determined to persist. So today it was incredibly satisfying to witness something quite unique.

Today, he ambulated 4 times the distance he ever has before, with minimal use of a quad cane, one person supporting the UL, one min assist at the hips. The pattern was lovely, his independence incredibly improved. A day that made you appreciate being a physiotherapist.

And interestingly, the key seemed to be in his UL. We had experimented previously with UL facilitation in sitting. But today we chose to do MPG weight shift for increased weight bearing in his arms and improve weight shift. He then improved his trunk extensor activation and scapula setting, improved foot alignment in walking and posture. By facilitating the UL in his ambulation, he was centred, taking full weight through straight legs that we had struggled to get extended sufficiently for weight bearing. It was incredible to watch. And further more, he began to string words together. Where he previously mumbled yeah or no, he said a slurred version of "that's ok" and "my shoulder is hurting". It was incredible!!!!!!!

So lets not forget the UL. Lets not leave it to the OT's. It is instrumental in facilitating appropriate trunk control and therefore weight shift. The sensation of weightbearing through the upper limb facilitates this in patients post stroke and improves the subluxation. I will never again let the upper limb fall second priority in physiotherapy sessions!