Gennady Arkadjev
Massage Laboratory (Rus)
Stroke
Consequences
of stroke
1.
Compass method
2.
Method of the creation of the reflex and its activation
3.
Method of the connection of muscles through synergy
4. Standard
variant of recovery
Very
often the problem of gaining of motion of paralyzed limbs has not medical, but
pedagogic problem. It means that the motion of limbs is possible and the head
is able to control them, but it can’t be done because of the muscle weakness.
In
this case it is necessary to create the best conditions for the training of
each muscle group. It’s very important to choose such angles that make the
movement possible. Then everything should be done according to the basic
principles of training (principle of pendulum, succession, etc.) taking
into account a certain situation.
Compass method
In
the situation described above it would be a good thing to use “compass method”.
A
patient is lying on his back. He can’t stir a hand, but, as I’ve said, it is
already connected to the brain. I mean that there are attempts to toughen or
flex the elbow with the help of biceps. Connected muscle is the muscle that is
consciously controlled by the patient, but because of the weakness and weak
advancing of nerve impulse to paralyzed muscles, the arm is without motion. The
masseur puts his fist under the elbow of the patient similarly to the axis of a
compass needle in such a way that forearm of the patient could freely remain in
the horizontal position (like a compass needle). Thus, we except the influence
of gravity force and all possible friction forces on the movement in forearm
with the help of biceps. Then we choose the best angle when the movement is
possible and start to work. Ask the patient to flex the elbow.
If
“the head is connected to the muscle”, the movement will happen. Then train,
exercise the muscles.
You
can overcome the weak advancing of nerve impulse to paralyzed muscle in the
following way. As a rule, while trying to move the paralyzed limb, a patient
usually unnecessary toughens or moves his unaffected limbs, because he reminds
the previous (before the disease) motional experience. At the same time, that
too weak impulse (that is exists, as we have already found out) of controlling
the paralyzed muscle cannot declare itself, owing to the suppression of a more
powerful impulse, that goes to the toughening or moving muscles of the
unaffected limbs. As a result the necessary movement doesn’t happen.
In
order to avoid this problem, we put the limb in the optimal position, as it has
been already said earlier. And, if the words can’t help, keep the unaffected
limbs from unnecessary movements. In such a way we teach the patient to move
the affected muscle without toughening the whole body. Sometimes it is
necessary to show the patient which movements of the unaffected limbs are bad
for him. In this case the masseur presses the motor points of pain threshold
(in these unaffected limbs) until their relaxing (the unaffected limbs feel the
pain well). It doesn’t look like massage. It is training. But, don’t become a
sadist while trying to help the neighbour.
Method of the creation of the reflex and its
activation
If
there is only straining effort, movement or tension of the unaffected parts of
body (at the moment of trying to move affected limb), it is necessary to
“connect the muscle”. I mean, that we should work not with an arm or a leg. We
should work differentially with certain groups of muscles or even with separate
muscle bundles. (It’s a long story.)
So,
“method of the creation of the reflex and its activation“. The principle of
this method is the making of involuntary, reflex movements and their conversion
into the conscious state, which is controlled by the brain. Reflex muscle
tension and the movements of muscles happen unconsciously. It happens with the
help of reflex arch: stimulation – spinal marrow – impulse to the muscle –
movement or muscle tension. The same happens when a person touches something
hot. First of all he will snatch his hand away and then the pain will “get” his
brain.
Let’s
start to work with the patient. His arm and leg are not only without moving,
but also without any possibility of conscious muscle tension.
First
of all, as in any course of massage, it is necessary to adapt the muscles. (See
chapters “Reference types of the body response to the first massage”, “Massage
plus biopendulum” or “Methodical peculiarities of making massage in the
conditions of radiation”.) It is a compulsory condition.
While working with a patient paralyzed after a stroke, give him a stress
that will cause only B or C-reaction. Then recover the stressed during the
first massage muscles and tissues with the second session. It is necessary to
balance this pendulum in the diurnal rhythm.
If you achieved it, continue increasing the amplitude of biochemical
processes of the “stress – recovery” cycle of the affected muscles and tissues
until the moment when the affected muscle react by a minimum tension. If there
is a result – it’s great! The début is won! And for the end game we have
“prepared” “method of the creation of the reflex and its activation”. Control
any attempts of involuntary muscle tensions. If there is none, it is necessary
to make them with the help of tonic exercises (Technique of massage. See
chapter “Massage plus biopendulum”). Sometimes 5-7 sessions pass before a
muscle react with some slight tension. When you “caught” this tension, train,
exercise this muscle group with intensive tonic massage. In this case the
massage intensity is limited to pain threshold and is near it. During such
sessions it is necessary to control arterial pressure. It is very important to
say that all these sessions should be done only when the patient feels well.
Otherwise massage can cause exacerbation. If the patient feels unwell, make him
feel well by using adaptation (in the form of B or C-response to the first
massage). So, in response to the stimulation of some points and zones, one of
the paralyzed muscles tenses. But we should be interested not in small, but
only in big muscle groups to “switch on the muscle pumps” in them. The recovery of a paralyzed muscle can be
compared with a revolution. The success
of any revolution depends on the preparation quality and certain conditions.
The work of the pumps of the big muscle groups stimulates the blood supply and
muscle nourishment, not only for these muscles, but also for the tissues of the
whole limb. It creates the conditions for the rapid recovery. (See chapter
“Muscle pump, the principle of its work”) Then, the muscles, that we are
interested in, should be in the direct contact with the connected muscles and
tissues. In the near future, when favourable conditions are created, it will
allow us to use “the method of synergy”. (But we will speak about it later.)
After some tonic massage sessions this muscle group will be more
sensitive. The points of activation will appear. And accordingly a moment of a
small involuntary movement of an arm or a leg will appear in response to the
more powerful exposure of the masseur on these points or a muscle bundle. (The
moment of “reflex recovery”) At this moment we must divert our attention from a
“pure” massage and start to work with the appeared movement. At the beginning
there will be 3-5 weak movements and after that the muscle will be drained of
all strength. The next 3-5 minutes use recovering massage methods that will
lead to the lymph outflow. Then the cycle is repeated several times depending
on the patient’s level of health and the condition of his connected muscle.
The next phase is the increase of the muscle strength with the method
described above. The amount of points and active zones of influence will
increase during 5-10 sessions, and the impact on them will decrease. These
points and active zones will cause involuntary movements. It is important to
ask the patient to help. For example, ask him to try to move his arm or leg in
the necessary direction in the moment of making involuntary movement. In the
beginning the patient himself should try to move, and only in a second after
his feeble attempt, the practitioner massaging the prepared point causes an
active movement in his limb. In such a way the masseur and the patient start to
work at the “connection” of the muscle group to the consciousness. And finally,
during such a work it will appear a moment, when the masseur causes involuntary
movement in his arm or leg by light touch to the point. During one of such
sessions the masseur asks the patient to make 5-7-10 movements. At the
beginning the masseur influences on the point. But in the middle of the
session, when he sees that the patient moves his limb himself, he moves aside
showing that the patient can control the limb without any help. It will stir up
good emotions. Then we continue the activation of another muscle groups. What
concerns the connected muscle group, the patient continues to work with this
group himself, but under the masseur’s control.
Method of the connection
of muscles through synergy
It is more economical and sparing method for the patient and for the
masseur.
The main idea of this method is that there are two types of muscles:
antagonists and synergists. The former work in the opposite regimen (we don’t
need them), the latter work in the simultaneous one. It means that the
synergists function in one and the same way (for example, erector muscle of
spine and quadriceps muscle of thigh while getting up, etc.). And now imagine
the situation when one of the synergist is connected, but the other is not. The
masseur asks to put the controlled muscle in motion, and at this moment make in
the paralyzed limb certain angles that are similar to the movement of this
synergic pair. As a result we may see a movement of the paralyzed muscle and, of
course, the movement of the limb. That’s great! It seems to be magic. But we
should work hard for this. We should create necessary conditions. The
situation, when the synergists start to work together, is not clear. But we
understand that it necessary to massage the certain synergic pair and at the
same time we should be very careful. We should avoid muscle tension in
paralyzed limb.
And now, briefly about the all above:
1. Massage starts with big muscle bundles, which are in contact with the
“connected” muscles and tissues. It is done for further search of synergic
pairs and for the “switching on the muscle pumps”.
2. The first 3-4 sessions are done for adaptation of the patient and his
certain tissues to further sessions of “reflex recovery”. The competent
adaptation will help to avoid unnecessary complications during the course of
rehabilitation. It means that the masseur should take into consideration
personality trait of the patient and his disease.
Standard variant of
recovery
A bed-ridden patient, 65 years old, discharged from a hospital. The
woman can’t move her right arm and leg. Her consciousness is clear (it is very
important). But she can’t sustain tension for a long time (for example, she
can’t watch TV more than 20 minutes), because she feels unwell.
During the first sessions we analyze the state of the patient according
to the responses of the muscles. For example, in the case of a headache (D and
E types of reactions) we should exclude all the load-types of massage while
using restorative methods of massage. At the end of the session we should use
sedative type of massage of the head (sometimes we may also make facial
massage) till the patient falls asleep.
Little by little try to achieve stable state.
According to the appeared hyper-tonus of the biceps and flexor muscle of
thigh, we may detect that the state of the patient becomes better. (When a
patient has a headache or feels unwell, he has amyotonia.) In the neglected
situations hyper-tonus of these muscle groups is bad for the recovery. But in
this case we will use this “bad feature” as stimulation for the first clonus in
the arm. Single out big muscle groups of the arm: biceps, triceps and deltoid
muscle. We should work with the whole arm laying special emphasis on the work
with these muscle groups. (I don’t recommend you to work with the patient’s
hand too hard, because at this stage you will just lose the time.)
During 3-4 sessions we should adapt the muscles of the patient. In the
case of ill health of the patient, adaptation will take longer period of time.
Then we use pathologic hyper-tonus of the biceps and try to activate the
reflex in its zone, though we should search for the points on the whole
shoulder and forearm. It is such an individual work that I don’t even try to
generalize the information. There is no analogy with the acupuncture points.
The localization of the motor points for the reflex recovery is very
unpredictable. It is clear that they exist, if not we should create them. In
2-4 sessions we cause the first movement. (It happens when we caught the tense
of the biceps after the influence on the point in the cubital region.) When the
process is activated, we start to work hard at this movement. Taking into
consideration the fact that the patient can’t sustain more than 3 load
sessions, we choose the cycle of 2-3 sessions of hard work. Then follow
sedative-restorative session or a day off. The next cycle (3+1) was without any
changes. The flexion of elbow is better, but we still have the involuntary movement.
In the middle of the cycle I catch a little tension of the biceps when the
patient tries to move the forearm. It happened on coughing. While coughing a
bed patient bows the head and tries to raise herself by means of tension of
pectoral muscles and prelum abdominale muscles. I ask the patient to repeat
this movement and at this moment I control the biceps tension. In the efforts
to obtain the bad leg we can catch the moment of a little flexion of elbow and
adduction of the upper arm to the body. We don’t need the latter movement, so
we press the upper arm to the body to avoid the adduction of the limb. The
synergists to the paralyzed biceps will be, in this case, the group of pectoral
muscles and the prelum abdominale muscles. Though the pectoral muscle (at the
affected part of the body) works, it is still too weak. That’s why we use the
movement of the unaffected arm in the direction of the bad leg to strengthen
the joint action of the both pectoral muscles and to amplify the impulse to the
paralyzed biceps by means of synergy.
Then I choose an optimal angle in the elbow joint, which is similar to
the full extension. At this moment I support the forearm to avoid the wrong
movement amplitude. Then I ask to make 5 trained movements (an effort to reach
an unaffected hand to the opposite leg). In this case we observe a considerable
flexion of elbow. I alternate this exercise with the moments of relaxation,
during which I give a restorative massage of the working muscles. So, after the
connection of the biceps through synergy to the pectoral muscle and prelum
abdominale during one cycle, we were training the flexion of elbow by means of
the movement described above. At the same time we were decreasing little by
little the range of training motion (reach an unaffected hand to the opposite
leg) and were increasing the range of the working motion of the muscles
(flexion of elbow). In the end we could do without any auxiliary movements.
During further training of the weakened muscle we used the “compass method”. So,
the biceps brachial muscle is “connected”.
Using the synergy of the biceps work and the work of the flexor muscle
of the hand (in the forearm) we can easily force the patient to clench the
fist. It is enough just to ask the patient to make the trained flexion of elbow
securely fixing the forearm. And, as the insertion sites of the biceps and the
flexor muscle of hand cross at the point of elbow, and these groups of muscles
work themselves as synergists (i.e. in the same regimen), the patient as often
as not makes a fist. Then train. Now, the part of the problem is solved. Then
work in the same way with the triceps brachial muscle and the extensor muscle
of forearm. But in this case the synergists for the triceps will be the
extensor muscles of back and neck.
The work with the paralyzed leg is very similar, but it is much quicker.
Activate the reflex of the rectus muscle of thigh. Then train the lifting of
the leg with passive flexion of knee. But the main movement that is important
for the gain of motion – is the extension of knee joint (it means the work of
quadriceps muscle of thigh). Almost in
all situations the synergists of the quadriceps muscle are the gluteus and the
erector muscle of spine.
Ask the patient to raise a little her pelvis. Everything is fine. We
managed to do it. Then we bend gently the knee of her paralyzed limb, and at
the same time we must fix and hold the foot of this leg. By analogy the patient
sets her unaffected foot in such way as to raise the pelvis. Then ask her to
raise the pelvis fully over the bed. After that we train this movement.
Meanwhile we control the state of the quadriceps muscle of thigh. Correct the
movement in the unaffected leg and the angle of knee flexion in the affected
leg. The raise of the pelvis should stimulate the tension of the quadriceps
muscle of thigh of the paralyzed limb. When this tension is well-marked, we
should ask the patient to push the masseur’s hand that fixes the paralyzed
foot. If the patient managed to do it, we may say that the quadriceps muscle of
thigh is connected. Then training should follow. The work with the paralyzed
leg is easier than with the arm. But there is another problem. Legs should
carry the weight of the whole body when a person walks. That’s why we should
pass from trainings in the lying position to trainings in the sitting position.
The main task is to recover the force potential of the both legs and to make
the knee and the ankle joints stronger. The first problem of this disease is
hypermobility of the joint (because of the weakness of muscles and inability of
these muscles to hold the joint). That’s why, when we pass on to the vertical
position (during the recovery process), first of all suffer the lumbar spine,
the knee and the ankle joints of both legs. The unaffected leg suffers because
of the excessive overload (the basic load is on this leg) and the recovered leg
suffers because of the muscle weakness and because of the unbalanced tension of
the muscles. As the flexor surface of thigh often has hyper-tonus, so we must
overcome this problem at the process of training. By this period we must
prepare the above-mentioned joints spending more time on them during massage.
Then follows the differential force training of these muscle bundles in the
joints’ range. The second problem is more serious. Any work that is connected
with quadriceps muscle of thigh has a force character, and, as a rule, the
cardiovascular system is involved in this work. That’s why during the trainings
(when pass on to the vertical position) it is necessary to control pulse and
blood pressure. During massage and training exercises it is very important to
catch the individual biopendulum of the “stress – recovery” cycle and adhere
strictly to it. (See chapter “Life pendulum”).
At the beginning of this work it is told about the recovery of the
muscles of the paralyzed arm. Though in practice, we pay attention to the leg
and to the recovery of the ability to move without assistance. It was done in
order to describe easily the problem of the recovery of the limbs paralyzed
after a stroke.
Of course, it is impossible to describe on 7-8 pages all the nuances of
the rehabilitative process after the insult. The above-stated is just the
search directions for the masseur.
I want to tell you about the common errors that some specialists’
recommendations contain:
1. “If you can’t stir the fingers, you should bend and unbend them with
the help of the unaffected hand“.
2. “If you can’t stir your arm, so you should make passive movements of
this limb. Move it up and sideways, etc. with the help of the unaffected hand”.
It is clear that the aim of this exercise is to increase the mobility of
the shoulder joint. Its condition is characterized by the tonus of the deltoid
muscle. But the muscle is atrophied and can’t hold the shoulder joint. (See
chapter “Features, state and tonus of an “ideal” muscle”) In this case we
should use a special sling to relieve the tension of the shoulder joint. During
the recovery of the deltoid muscle and the appearance of little tonus, the shoulder
joint pain will disappear.
And if somewhere from a specialist you hear similar recommendations, get
out of there. At best you’ll just lose you time and money.
Now it makes sense to speak about psychological aspects of recovery
process. It is terrible if the patient loses his faith in the possibility of
recovery.
First of all, the patient should feel the confidence in it. It can be
achieved in a simple way. The masseur examines the patient and then explains to
him when and what will happen during the recovery process. For example, the
masseur has counted that the training of the quadriceps muscle of thigh and the
reflex recovery will take a week. He can tell the patient about it. The patient
himself will see the intermediate results of the work (its progress). The
practical confirmation of masseur's words will have better effect than any
hypnosis. The patient will consciously take part in the gain of motion process.
If you could gain any result during the first sessions, it arouses hope in the
patient, the faith in recovery and wish to continue the recovery process.
To be continued…
November 22, 2002
Gennady Arkadjev Massage Laboratory (Rus)
