Neuromuscular 1 Final Exam
Describe the role of the CT scan in the diagnosis of acute stroke and the implementation of emergency medical measures.
CT scan is a neuroimaging technique that allows identification of large arteries and veins, and venous sinuses. Acute bleeding and hemorrhagic transformation are visible on CT scanning. Early computed tomography (CT) is used to differentiate between atherothrombotic stroke and hemorrhagic stroke. If the stroke is atherothrombotic, clot-dissolving enzymes (e.g. tissue plasminogen activator [tPA]) can be used for thrombolysis. To be effective, thrombolytic therapy such as tPA must be given within 3 hours of the onset of symptoms and cannot be given with hemorrhagic stroke because the drug may worsen bleeding. Within this window of opportunity, the patient must recognize the situation as a medical emergency, be transported to an appropriate hospital, be evaluated by emergency room staff including receiving a CT scan of the brain, and be treated.
Non-fluent Aphasia
(Broca's/ expressive aphasia), the flow of speech is slow and hesitant, vocabulary is limited, and syntax is impaired. Speech production is labored, or lost completely, while comprehension is good. The lesion is located in the premotor area of the left frontal lobe. Global aphasia is a severe aphasia characterized by marked impairments of both production and comprehension of language. It is often an indication of extensive MCA brain damage.
Fluent Aphasia
(Wernicke's/ sensory/receptive aphasia), speech flows smoothly with a variety of grammatical constructions and preserved melody of speech. Auditory comprehension is impaired. Thus, the patient demonstrates difficulty in comprehending spoken language and in following commands. The lesion is located in the auditory association cortex in the left lateral temporal lobe.
Describe the behaviors of the patient with stroke who demonstrates 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 postero- lateral thalamus. The result is an altered perception of the body's orientation in relation to gravity. Patients experience a misperception of subjective postural vertical (SPV) position, perceiving their body as vertical when it was actually tilted about 20° toward the hemiparetic side. Visual and vestibular in- puts for orientation perception to vertical remained intact as patients were able to align their bodies with the help of visual cues and conscious strategies.
What scores are used to document an increased DTR?
A normal response is slight contraction of knee extensors (graded 2+/4). Brisk reflexes are possibly (but not necessarily) abnormal and are graded a 3+/4. Very brisk reflexes are considered abnormal and may appear with clonus. They are graded a 4+/4.
Assume you are about to initiate a coordination examination. What screenings would be appropriate?
A screening of ROM, strength, and sensation prior to the coordination examination will improve validity because impairments in any of these areas may influence the ability to produce smooth, accu- rate, controlled motor responses. However, it is also important to note that coordination impairments may occur in the presence of normal ROM, strength, and intact sensation.
What are the elements of a well-built research question?
A well-built research question contains three elements: (1) a specific patient/client group or population, (2) the specific interventions or exposures to be studied, and (3) the outcomes achieved.
Differentiate between impairments, activity limitations, and participation restrictions. Define and give an example of each.
Activity limitations are difficulties an individual may have in executing tasks or actions. Activity limitations can include limitations in the performance of cognitive and learning skills, communication skills, functional mobility skills, and activities of daily living. Example: The same patient with stroke has difficulty transferring independently (maximum assistance) or walking (unable), requires supervision in wheelchair mobility, and requires maximum assistance in bathing and dressing with minimum assistance in eating.
What are the advantages of electronic documentation systems? Disadvantages?
Advantages: standardization of data entry, increased speed of access to data, and integration of data that can be used for a wide variety of applications (e.g., clinical management of patients, quality control, clinical research) Disadvantages: initial expense of portable computer systems and training
Describe the five terms used to document a patient's level of consciousness.
Alert. The patient is awake and attentive to normal levels of stimulation. Interactions with the thera- pist are normal and appropriate. Lethargic. The patient appears drowsy and may fall asleep if not stimulated in some way. Interactions with the therapist may get diverted. Patient may have difficulty in focusing or maintaining attention on a question or task. Obtunded. The patient is difficult to arouse from a somnolent state and is frequently confused when awake. Repeated stimulation is required to maintain consciousness. Interactions with the therapist may be largely unproductive. Stupor (semicoma). The patient responds only to strong, generally noxious stimuli and returns to the unconscious state when stimulation is stopped. When aroused, the patient is unable to interact with the therapist. Coma (deep coma). The patient cannot be aroused by any type of stimulation. Reflex motor responses may or may not be seen.
A patient with multiple sclerosis reports fatigue as the number one symptom that impairs func- tional independence in the home environment. How should this patient's fatigue be examined and documented?
An examination of fatigue begins with the initial interview. The patient is asked to identify those activi- ties that are fatiguing, the frequency and severity of fatigue episodes, and the circumstances surrounding the onset of fatigue. It is important to identify the fatigue threshold, defined as that level of exercise that cannot be sustained indefinitely. Self-assessment questionnaires are particularly useful in the patient with significant fatigue. One example is the Modified Fatigue Impact Scale (MFIS), an instrument ini- tially developed to assess quality-of-life problems related to fatigue in patients with multiple sclerosis. It includes questions on the cognitive and social domains, as well as physical performance.
Describe equipment (items) that can be used to assess stereognosis.
Any number of small, culturally appropriate items can be used to examine stereognosis. Examples include comb, fork, paper clip, coin, pen, and key.
What are the major types of aphasia that can result from stroke? Where are the lesions located?
Aphasia is the general term used to describe an acquired communication disorder caused by brain damage and is characterized by an impairment of language comprehension, formulation, and use. Major classification categories are fluent, nonfluent, and global.
Identify three upper extremity and three lower extremity nonequilibrium coordination tests that could be used to examine a patient with severe ataxia as a result of traumatic brain injury.
As the patient has severe ataxia, supported sitting should be used for the upper extremity tests and the sitting or supine position for the lower extremity tests. Upper extremity nonequilibrium tests might include finger-to-nose, finger-to-therapist's finger, finger-to-finger, alternate nose-to-finger, pointing and past pointing, and tapping (hand). Lower extremity nonequilibrium tests might include tapping (foot), alternate heel-to-knee and heel-to-toe, toe-to-examiner's finger, heel on shin, drawing a circle, and fixation (position holding).
What is a fibrillation potential on electromyography (EMG)? What is it indicative of?
Fibrillation potentials are believed to arise from spontaneous depolarization of a single muscle fiber. They are not visible through the skin. Fibrillation potentials are biphasic spikes, classically indicative of lower motor neuron disorders such as peripheral nerve lesions, anterior horn cell disease, radiculopathies, and polyneuropathies with axonal degeneration. They are also found to a lesser extent in myopathic diseases such as muscular dystrophy, dermatomyositis, polymyositis, and myasthenia gravis. Their sound is a high-pitched click, which has been likened to rain falling on a roof or wrinkling tissue paper.
Describe how the data from the examination of sensory function are used by the physical therapist.
Findings from the examination (i.e., history, systems review, tests, and measures) are synthesized during the evaluation process to make a diagnosis (including the process of differential diagnosis).
What type of findings from an examination of sensory function would indicate that a referral is warranted?
Findings that are inconsistent with the diagnosis or findings that suggest the patient has an undiag- nosed condition would indicate that a referral is warranted.
For a suspected localized lesion, in which direction would you conduct your examination of sensory function and why?
For a suspected localized lesion, sensory function is examined in a distal to proximal direction since conditions tend to affect the distal segments first. Using this direction can also indicate the severity of the condition.
Differentiate between impairments, activity limitations, and participation restrictions. Define and give an example of each.
Impairments are the problems an individual may have in body function (physiological functions of body systems) or structure (anatomical parts of the body). The resulting significant deviation or loss is the direct result of the health condition. Example: A patient with stroke presents with sensory loss, paresis, dyspraxia, and hemianopsia (direct impairments). The patient also presents with decreased vital capacity and endurance, disuse atrophy and weakness, and contracture (indirect impairments) as well as balance and gait deficits (composite impairments).
Differentiate between the use of performance observations and retention tests in providing evidence of motor learning.
Improvements in performance during practice have been used to assess motor learning. Performance cri- teria are established and used for comparison to determine the success of learning outcomes. Qualitative changes in performance compared to the criterion skill can also be used to document motor learning. Retention refers to the ability of the learner to demonstrate the skill over time and after a period of no practice (retention interval). A retention test, defined as a performance test administered after a retention interval, can be used for the purposes of assessing learning.
Delayed reaction time
increased time required to initiate voluntary movement
Tremor
involuntary oscillatory movement resulting from alternate contractions of opposing muscle groups
Chorea
involuntary, rapid, irregular, jerky movements involving multiple joints; most apparent in upper extremities
Tremor (resting)
involuntary, rhythmic, oscillatory movement observed at rest
Hemiballismus
large-amplitude sudden, violent, flailing motions of the arm and leg of one side of the body
Asynergia
loss of ability to associate muscles together for complex movements
Choreoathetosis
movement disorder with features of both chorea and athetosis
Dyssynergia
movement performed in a sequence of component parts rather than as a single, smooth activity; decomposition
Titubation
rhythmic oscillations of the head; axial involvement of the trunk
Nystagmus
rhythmic, quick, oscillatory, back-and-forth movement of the eyes
Athetosis
slow, involuntary, writhing, twisting, "wormlike" movements; frequently greater involvement in distal upper extremities
Dystonia (dystonic movements)
sustained involuntary contractions of agonist and antagonist muscles
Differentiate between coordination tests for intention tremor and postural tremor.
Intention tremor appears during voluntary movement. Movements are observed for steadiness (oscillations) and accuracy. Upper extremity tests might include finger-to-nose, finger-to-therapist's finger, finger-to- finger, alternate nose-to-finger, and pointing and past pointing. Lower extremity tests might include alternate heel-to-knee and heel-to-toe, toe-to-examiner's finger, and heel on shin. Postural tremor is an unsteadiness of the head, neck, and trunk that is present at rest and may worsen with voluntary movements of the extremities. Observe for steadiness (oscillations), postural sway, and fall risk.
How should stability be examined?
Key elements the therapist should observe and document include (1) BOS, (2) position and stability of the COM within the BOS, (3) the degree of postural sway, (4) degree of stabilization from upper or lower extremities (e.g., handhold, hooked legs), (5) number of episodes and direction of loss of balance (LOB) and fall safety risk, (6) level and type of assistance required (manual cues, verbal cues, guided movements); and (8) environmental constraints that influ- enced performance.
What are the key steps in patient/client management?
Key steps in patient/client management include (1) examination of the patient, (2) evaluation of the data and identification of problems, (3) determination of the physical therapy diagnosis, (4) determination of the prognosis and plan of care (POC), (5) implementation of the POC, and (6) reexamination of the patient and evaluation of treatment outcomes.
Differentiate between impairments, activity limitations, and participation restrictions. Define and give an example of each.
Participation restrictions are problems that an individual may experience regarding involvement in life situations and societal interactions. Categories of life roles include home management, work (job/school/play), and community and leisure. Example: The same patient with stroke (age 42) is unable to live independently at home (home management skills) and is unable to drive or return to work as a computer programmer.
Explain cerebral artery syndromes in terms of expected deficits - MCA
The middle cerebral artery (MCA) supplies the entire lateral aspect of the cerebral hemisphere and subcortical structures, including the internal capsule (posterior portion), corona radiata, globus pallidus (outer part), most of the caudate nucleus, and the putamen. Occlusion of the proximal MCA produces extensive neurological damage with significant cerebral edema. Increased intracranial pressures typically lead to loss of consciousness, brain herniation, and possibly death. The most common characteristics include contralateral spastic hemiparesis and sensory loss of the face, UE, and LE, with the face and UE more involved than the LE. Lesions of the parieto-occipital cor- tex of the dominant hemisphere (usually the left hemisphere) typically produce aphasia. Lesions of the right parietal lobe of the non-dominant hemisphere (usually the right hemisphere) typically produce per- ceptual deficits. Homonymous hemianopsia (a visual field defect) is also a common finding. The MCA is the most common site of occlusion in stroke.
Describe the examination of a hyperactive patellar deep tendon reflex.
The deep tendon reflex (DTR) results from stimulation of the stretch-sensitive IA afferents of the neuro- muscular spindle, producing muscle contraction via a monosynaptic pathway. It is tested by tapping sharply over the muscle tendon with a standard reflex hammer or with the tips of the therapist's fin- gers. To ensure adequate response, the muscle is positioned in midrange and the patient is instructed to relax. In this example, the patient sits with the knee flexed and foot unsupported. The tendon of the quadriceps muscle is tapped between the patella and the tibial tuberosity.
What is the highest level of evidence available for evidence-based clinical practice guidelines?
The highest level of evidence available for Evidence-Based Clinical Practice Guidelines is systematic review of multiple randomized controlled trials (RCTs) followed by individual RCTs.
Compare the advantages and disadvantages of a kinematic qualitative gait analysis with the advantages and disadvantages of a kinematic quantitative analysis.
The major advantage of a kinematic qualitative analysis is the relative ease in which it can be performed, and the fact that it usually requires little equipment and therefore is less expensive than instrumented analyses. The disadvantage is that this type of analysis is subjective and has only low to moderate reliability. The major advantage of a kinematic quantitative analysis is that it provides measurable objective data on temporal and spatial variables that can be tested for reliability and validity. The disadvantage is usually the expense associated with more sophisticated equipment (e.g., an instrumented walkway). However, a number of measures can be quantified using simply a stopwatch to measure variables across a fixed walk- ing distance (e.g., walking velocity, average gait cycle time, cadence, and average stride length).
How can the levels of consciousness and arousal influence the motor function examination?
Very low or high levels of arousal can cause deterioration in motor performance. Critical components for baseline examination of the autonomic nervous system (ANS) include (1) a representative sampling of ANS responses, including heart rate (HR), blood pressure (BP), respiratory rate (RR), pupil dilation, and sweating; (2) a determination of patient reactivity, including the degree and rate of response to stimulation; and (3) a determination of physiological stressors (e.g. environmental factors).
Fugl-Meyer Assessment of Physical Performanec (FMA)
an impairment-based test with items organized by sequential recovery stages. A three-point ordinal scale is used to measure impairments of volitional movement with grades ranging from 0 (item cannot be performed) to 2 (item can be fully performed). Specific descriptions for performance accompany individual test items. Subtests exist for UE function, LE function, balance, sensation, ROM, and pain. The cumulative test score for all compo- nents is 226 with availability of specific subtest scores (e.g., UE maximum score is 66, LE score is 34; balance score is 14). This instrument has good construct validity and high reliability (r = 0.99) for determining motor function following stroke (a gold standard instrument).
Gait disorders
ataxic pattern; broad base of support; postural instability; high-guard position of upper extremities
Dysdiadochokinesia
impaired ability to perform rapid alternating movements
Reboud phenomenon
inability to halt forceful movements after resistive stimulus removed; patient unable to stop sudden limb motion
Akinesia
inability to initiate movement; associated with fixed postures
Dysmetria
inability to judge the distance or range of a movement
Identify at least one variable from each type of analysis and describe a technique/technology that could be used to examine the variable - Kinematic qualitative analysis
include deviations from normal postures, such as trunk leans (forward, backward, ipsilateral, or contralateral), pelvic drops or hikes, excessive or limited flexion or extension of the hip or knee, excessive plantarflexion or dorsiflexion of the ankle, or a drag of the toes. All of these deviations represent variables that might be examined with a kinematic qualitative analysis. The Observational Gait Analysis (OGA) system by Rancho Los Amigos could be used to observe the patient's gait and identify the presence and severity of the deviation.
Rigidity
increase in muscle tone causing greater resistance to passive movement; greater in flexor muscles
Define a dermatome and describe a precaution with using published dermatome maps.
A dermatome refers to the skin area supplied by one dorsal root. A precaution is that some inconsistencies exist in the dermatome maps used in education and practice.
Differentiate between restorative and compensatory interventions. Give an example of each.
Compensatory interventions (compensatory approaches) are directed toward promoting optimal function using residual abilities. The activity (task) or environment is adapted (changed) to achieve function. The uninvolved or less involved segments are targeted for intervention. Example: The patient with severe stroke and cardiovascular comorbidities undergoes wheelchair mobility training using the sound upper extremity (UE) and lower extremity (LE) for independent home locomotion.
Describe how a therapist would determine the concurrent validity of temporal and spatial gait measures recorded using the GAITRite with values calculated using the Stride Analyzer.
Concurrent validity is determined by comparing the results obtained with a test of interest (e.g., tempo- ral and spatial variables measured with the GAITRite) and values measured with another technique or method that has previously been shown to be valid (sometimes referred to as the "gold standard"). If the results of the test of interest strongly agree with the results of the test already shown to be valid, then the two measures are said to have concurrent validity.
Describe the examination of consciousness and arousal.
Consciousness refers to a state of arousal accompanied by awareness of one's environment. Levels of con- sciousness vary from full consciousness to progressively decreasing levels (lethargy, obtunded state, stu- por, and coma). Consciousness should be examined first in the motor function examination and will indicate the patient's readiness to participate in rehabilitation (examination and intervention).
A patient with stroke exhibits abnormal control of eye muscles and is unable to move the eyes smoothly in all directions. Cranial nerve testing should include what nerves and tests?
Cranial nerves III, IV, and VI are purely motor and control pupillary constriction and eye movements. During the examination, the patient is asked to look in each direction (saccadic eye movements) and follow a moving finger (pursuit eye movements). The resting position of the eye should also be observed for deviations from the normal conjugate position (e.g., strabismus).
Identify six pathologies or health conditions that would warrant (or indicate the need for) examination of sensory function.
Examples of pathologies or health conditions that typically warrant examination of sensory function include stroke, multiple sclerosis, amyotrophic lateral sclerosis, spinal cord injury, amputation, and diabetes.
What information would you provide to the patient prior to administration of sensory tests to obtain informed consent?
Disclosure to the patient would include information about the test (e.g., its purpose, procedure, and alternatives), expected benefits and risks, and the likelihood that the benefits and risks will occur.
Describe the variables you would use to record the results of sensory testing.
Documentation should include the sensation tested, the body part examined (extremity vs. trunk, distal vs. proximal), the side (right or left), grade, and any additional comments.
How can spasticity and rigidity be examined?
Examination involves passive motion testing, which reveals information about the responsiveness of muscles to stretch. Because these responses should be examined in the absence of voluntary control, the patient is instructed to relax, letting the therapist support and move the limb. During a passive motion test, the therapist should maintain firm and constant manual contact, moving the limb in all motions. Varying the speed of movement is an important determinant of spasticity. In a spastic limb, resistance will be lower at slow speeds compared to when the limb is moved at faster speeds. Faster movements intensify the resistance to passive motion. With rigidity, resistance to passive motion is constant and not influenced by the speed of passive motion.
What are the essential elements of goal and outcome statements?
Goal and outcome statements should be realistic, objective, measurable, and time limited. There are four essential elements. Individual: Who will perform the specific behavior or activity required or aspect of care? Behavior/Activity: What is the specific behavior or activity that the patient/client will demonstrate? Condition: What are the conditions under which the patient's/client's behavior is Time: How long will it take to achieve the stated goal or outcome? Time: How long will it take to achieve the stated goal or outcome? Goal scan be. expressed as short-term (generally considered to be 2 to 3 weeks) or long-term (longer than 3 weeks).
How could a gait analysis of temporal parameters be used to demonstrate a patient's progress or lack of progress?
If the therapist sets a goal of decreasing the time it takes to complete a walk of a certain distance and the patient is able to meet that goal, then it would be considered progress. Lack of progress would be indi- cated if the time it takes to walk the distance either stays at baseline level or fails to meet the goal.
Describe the three different types of gait analyses (kinematic qualitative, kinematic quantitative, and kinetic) and list the variables examined in each type.
Kinematic gait analysis is used to describe movement patterns without regard for the forces involved in producing the movement. It consists of a description of body movement as a whole and/or body segments in relation to each other during gait. A kinematic gait analysis can be either qualitative or quan- titative. The primary variable examined in a qualitative kinematic analysis is displacement, which includes a description of patterns of movement, deviations from normal body postures, and joint angles at specific points in the gait cycle. Kinematic quantitative analyses are used to obtain quantifiable information on spatial and temporal variables. Kinetic gait analyses are used to quantify the internal and external forces that occur during gait.
Identify at least one variable from each type of analysis and describe a technique/technology that could be used to examine the variable - Kinematic quantitative analysis
Kinematic quantitative analyses measure temporal variables such as velocity, speed, cadence, accelera- tion, stance and swing times, step and stride times, as well as spatial variables such as step length, stride length, step width, and width of base of support. Stride length is one kinematic quantitative variable that a clinician might want to measure. The Stride Analyzer, a footswitch system, could be used if avail- able or markers could be attached to the client's heels to allow quantification. In a gait laboratory or in some research settings, sophisticated technology (e.g., electrogoniometers and three-dimensional motional analysis systems) are also used to provide a quantitative kinematic analysis regarding measure- ments of the joint motions occurring throughout the gait cycle.
Identify at least one variable from each type of analysis and describe a technique/technology that could be used to examine the variable - Kinetic analyses
Kinetic analyses include an analysis of ground reaction forces (vertical, anterior-posterior, and medial- lateral) that occur as a result of foot contact with the supporting surface. Sophisticated mathematical equations can be used to infer the muscle demands occurring at different joints given knowledge of the ground reaction forces and joint positions. The center of pressure is the point of application of the resultant force. Pressure, a measure of force per unit area, is used to study the forces acting on the surface of the foot's plantar aspect. High pressures can lead to skin breakdown. This can be dangerous for indi- viduals who lack the normal sensation to feel the high pressure or who have inadequate circulation to heal from the tissue damage. Two kinetic variables that could be measured are peak plantar pressure and center of pressure excursion.
Differentiate between motor impairments associated with cerebellar pathology and basal ganglion pathology
Motor impairments associated with cerebellar pathology include: Asthenia, asynergia, delayed reaction time, dysarthria, dysdiadochokinesia, dysmetria, dyssynergia, gait disorders, hypotonia, hypermetria, hypometria, bystagmus, rebound phenomenon, tremor, and titubation. Motor impairments associated with basal ganglia pathology include: akinesia, athetosis, bradykinesia, chorea, choreoathetosis, dystonia, hemiballismus, hyperkinesis, hypokinesis, rigidity, and tremor
Asthenia
generalized muscle weakness
How is peripheral feedback provided during a motor response?
Peripheral feedback during a motor response is provided by muscle spindles, Golgi tendon organs, joint and cutaneous receptors, the vestibular apparatus, and the eyes and ears. This feedback provides contin- ual input regarding posture and balance, as well as position, rate, rhythm, and force of slow movements of peripheral body segments. If the input from the feedback systems does not compare appropriately (i.e., movements deviate from the intended command), the cerebellum supplies a corrective influence.
Identify methods that can be used to determine the energy costs that a patient incurs while walking.
Physiological energy cost can be determined by measuring oxygen uptake during walking. The oxygen cost per unit of distance walked per unit of time reflects the power of walking and reflects gait efficiency. Measurements of the oxygen rate reflect energy expenditure per unit of time. The Douglas bag method is used to obtain the oxygen uptake. Heart rate (HR) data are used to determine the relative energy cost of gait. A telemetry system that produces beat-by-beat information as well as electrocardiographic activity is the most accurate way to obtain HR data. Knowledge of the patient's medications and dosages is important as some can blunt HR, rendering HR response an inaccurate estimate of energy cost for a specific patient.
A new client is referred to physical therapy with gait dysfunction arising from severe diabetic sensory and motor neuropathy. He recently received a new pair of custom-molded orthotic shoe inserts and was instructed to use them in his shoes to help reduce plantar pressures. Unfortunately, he is unable to feel whether they are fitting or not, secondary to the sensory neuropathy. What technology could be used to assess the effectiveness of the inserts at reducing plantar pressures? What activities should be assessed and why?
Plantar pressures can be measured as the client walks at a comfortable speed as well as at slow and fast speeds to determine whether the insoles are providing sufficient pressure relief, particularly under the first metatarsal head regions. Using different walking speeds will help the patient understand how the choice of speeds may impact pressures, particularly in the vulnerable forefoot region. It would also be useful to assess standing (static) pressures. Finally, testing pressures while barefoot will help the patient understand the relative impact of the insoles on plantar pressures.
Which type of sensory receptor is responsible for position sense and awareness of joints at rest, during movement, and vibration? How would you comprehensively examine this sensory receptor?
Proprioceptors are responsible for position sense and awareness of joints at rest, during movement, and vibration. To test proprioception, position the patient's extremity or joint(s) and ask the patient to de- scribe the position or replicate the position on the contralateral side. To test kinesthesia, while moving the patient's extremity or joint(s), ask the patient to describe the movement or replicate the movement on the contralateral side. For vibration, ask if and when the patient feels a vibrating tuning fork contact the body.
Differentiate between recovery of function and compensation.
Recovery of function is the reacquisition of movement skills lost through injury. The movements recov- ered may be performed exactly as before. In the patient with neurological damage, it is more often the case that the movements are modified and not performed exactly as before the injury. Compensation refers to the adoption of alternative behavioral strategies to complete a task. Movements utilize different muscles and strategies to substitute for the loss of function (e.g., the patient with stroke dresses using the less-involved upper extremity [UE]).
Differentiate between restorative and compensatory interventions. Give an example of each.
Restorative interventions (remedial approaches) are directed toward remediating or improving the patient's status in terms of impairments, activity limitations, participation restrictions, and recovery of function. The involved segments are targeted for intervention. Example: The patient with stroke undergoes treadmill training using body weight support and man- ual assistance of the therapist to promote stepping movements of the involved lower extremity.
How should selective and alternating attention be examined?
Selective attention can be examined by asking the patient to attend to a particular task. For example, the therapist asks the patient to repeat a short list of numbers forward or backward (digit span test). The therapist documents the number of digits the patient is able to recall. Alternating attention (attention flexibility) is examined by requesting the patient to alternate back and forth between two different tasks (e.g., add the first two pairs of numbers, then subtract the next two pairs of numbers).
Differentiate between selective attention and alternating attention.
Selective attention is the ability to screen and process relevant sensory information about both the task and the environment while screening out irrelevant information. The complexity and familiarity of the task determines the degree of attention required.
What are the believed contributions (function) of the cerebellum to coordinated movement?
Several theories of function of the cerebellum have been established. Among the more widely held theo- ries is that the cerebellum functions as a comparator and error-correcting mechanism. The cerebellum compares the commands for the intended movement transmitted from the motor cortex with the actual motor performance of the body segment. This occurs by a comparison of information received from the cortex with that obtained from peripheral feedback mechanisms (termed feedforward control).
Accurate and careful patient observation is an important source of preliminary information before performing a coordination examination. What type of activities would you select for the observation?
Since treatment intervention will be directed, at least in part, toward improving functional performance and activity levels, initial observations should logically focus here. Depending on the practice setting environment, the patient might be observed performing any number of functional activities such as bed mobility, self-care routines (e.g., dressing, combing hair, brushing teeth), transfers, eating, writing, changing position from lying or sitting to standing, maintaining a standing position, walking, and so forth.
Differentiate between spasticity and rigidity.
Spasticity is a motor disorder characterized by a velocity-dependent increase in muscle tone with increased resistance to stretch. It is associated with upper motor neuron (UMN) syndrome and lesions of the corti- cospinal tract. Rigidity is a hypertonic state characterized by constant resistance throughout range of motion (ROM) that is independent of the velocity of movement (lead pipe rigidity). It is associated with lesions of the basal ganglia system (extrapyramidal syndromes) and is seen in Parkinson's disease.
Define stability
Stability (static postural control) is the ability to maintain postural stability and orientation with the center of mass (COM) over the base of support (BOS) and the body at rest. For example, the patient demon- strates stability in sitting or standing if he or she is able to maintain the posture with minimum sway, no loss of balance, and no handhold.
How is nerve conduction velocity (NCV) calculated?
Subtraction of the distal latency from the proximal latency will determine the conduction time for the nerve trunk segment between the two points of stimulation. Conduction velocity (CV) is determined by dividing the distance between the two points of stimulation (measured along the surface) by the differ- ence between the two latencies (velocity = distance/time). CV = Conduction distance/(Proximal latency - Distal latency)
Differentiate between the Berg Balance Scale and the Performance-Oriented Mobility Test (Tinetti) in terms of aspects of balance tested.
The Berg Balance Scale examines static and dynamic balance in sitting and standing, proactive and reactive balance. It includes the functional items of sit-to-stand and stepping. It does not include any gait items. The Performance Oriented Mobility Test includes static and dynamic balance items in sitting and standing, proactive and reactive. It has two subtests: Balance and Gait. The scoring system is less discriminating (3-point scale) compared to the Berg Balance Scale (5-point scale).
What is the FITT equation for exercise intervention?
The FITT equation includes the following: Frequency: How often the patient will receive skilled care (e.g., number of times per week treatment will be given) Intensity: What is the prescribed intensity of exercises or activity training? (e.g., number of repetitions and sets) Time (duration): How long the patient will receive skilled care (e.g., total number of treatment sessions or weeks, duration of treatment sessions) Type of intervention: Specific exercise strategies or procedural interventions used.
Which type of muscle receptor senses tension and how does it affect the muscle when under extreme tension?
The Golgi tendon organ senses tension. Under extreme tension the Golgi tendon organ inhibits the muscle under tension (i.e., the agonist) and facilitates the antagonist.
Explain cerebral artery syndromes in terms of expected deficits - ACA
The anterior cerebral artery (ACA) is the first and smaller of two terminal branches of the internal carotid artery. It supplies the medial aspect of the cerebral hemisphere (frontal and parietal lobes) and subcorti- cal structures, including the basal ganglia (anterior internal capsule, inferior caudate nucleus), anterior fornix, and anterior four fifths of the corpus callosum. Because the anterior communicating artery al- lows perfusion of the proximal anterior cerebral artery from either side, occlusion proximal to this point results in minimal deficit. The most common characteristics of anterior cerebral artery (ACA) syndrome include contralateral hemiparesis and sensory loss, with greater involvement of the lower extremity (LE) than upper extremity (UE) because the somatotopic organization of the medial aspect of the cortex includes the functional area for the LE.
A person walks with excessive dorsiflexion, no heel-off, and limited toe extension in terminal stance. Hip and knee analysis reveals excess flexion during stance with absence of the normal "trailing limb" posture characteristic of terminal stance. Identify potential causes for these deviations. What addi- tional tests or measures should be performed?
The pattern of deviations is consistent with weak calf muscles. The calf muscles are unable to restrain forward collapse of the tibia in terminal stance. The ankle collapses into excessive dorsiflexion and the heel fails to rise from the ground, there is no need for the toes to extend. The knee and hip remain in excess flexion to accommodate the excessively dorsi- flexed posture of the foot. Alternatively, the individual could have painful metatarsal heads and want to avoid progressing body weight across the metatarsal heads. By avoiding heel rise (and remaining in excess dorsiflexion), forward progression of the center of pressure is restrained and a painful concentration of forces through the metatarsal heads is avoided. Excess knee and hip flexion are present to accommodate the ankle and foot posture. Palpation of the metatarsal heads and clinical questioning of the individual can be used to determine if metatarsal head pain could be contributing to the observed deviations.
What are the purposes of performing a coordination examination of motor function?
The purposes of performing a coordination examination of motor function are to determine the following: • Muscle activity characteristics during voluntary movement • Ability of muscles or groups of muscles to work together to perform a task or functional activity • Level of skill and efficiency of movement • Ability to initiate, control, and terminate movement • Timing, sequencing, and accuracy of movement patterns • Effects of therapeutic and pharmacological intervention on motor function over time
Describe four purposes of screening the sensory system.
The purposes of screening the sensory system are (1) to determine the need for a more detailed exami- nation of sensory function, (2) to determine if referral to another health-care practitioner is warranted (as part of differential diagnosis), (3) to narrow the search for the origin of symptoms to a specific region of the body, and (4) to identify system-related impairments (problems in body functions or structure) that contribute to activity limitations or participation restrictions.
Which muscles would you test to assess the spinal accessory cranial nerve?
The sternocleidomastoid would be tested (against resistance, have the patient slightly flex the head, side bend to the same side, and rotate to the opposite side) and the trapezius (against resistance, have the patient shrug both shoulders).
What are the issues of validity for using manual muscle testing as part of the examination of a patient with UMN syndrome (stroke) who exhibits strong spasticity and strong obligatory synergies?
The therapist must consider the patient's movement capabilities. Isolated joint move- ments, mandated by standardized MMT procedures may not be possible in the presence of UMN lesion where stereotypic abnormal movement patterns (obligatory synergies) are present. Also the presence of abnormal co-activation, spasticity, and abnormal posturing may preclude the patient's ability to perform isolated joint movements. These barriers to normal movement are termed active restraint. The prescribed test positions may also be precluded by the presence of abnormal reflex activity (e.g., supine testing influ- enced by presence of the tonic labyrinthine reflex). Muscle and soft tissue changes in viscoelasticity (e.g., contracture) offer a form of passive restraint and may also preclude the use of standardized testing. In these instances, the decision should be made not to use standardized MMT.
Explain why impaired sensation is a contraindication to or precaution for use of some physical agents.
Use of thermotherapy or cryotherapy on a patient that has impaired temperature awareness can lead to tissue damage or injury.
What information will the observation provide?
While observing the patient, general information can be obtained that will assist in localizing specific areas of impairment. This information will include the following: • General level of skill in each activity (amount of assistance or assistive devices required) • The occurrence of extraneous movements, oscillations, swaying, or unsteadiness • Number of extremities involved (unilateral and/or bilateral) • Distribution of motor impairment: proximal and/or distal musculature • Situations or occurrences that alter (increase or decrease) impairments • Amount of time required to perform an activity • Level of safety
Hyperkinesis
abnormally increased muscle activity or movement
Stroke Rehabilitation Assessment of Movement (STREAM)
clinical measure of voluntary move- ments and basic mobility following stoke. It consists of 30 items (test movements) distributed equally among three subscales: upper-limb movements, lower-limb movements, and basic mobility items. Volun- tary movement items explore out-of-synergy control and are scored using a 3-point ordinal scale (unable to perform, partial performance, complete performance). The basic mobility section includes a variety of items (rolling, bridging, sit-to-stand, standing, stepping, walking, and stairs) and is scored using a 4-point ordinal scale (unable, partial, complete/with aid, complete/no aid). The maximum score is 70 with each limb subscore worth 20 points and the functional mobility subscore worth 30 points. The instrument has good construct validity and high reliability and has been used to document motor recov- ery over time and predict discharge destination following stroke.
Hypotonia
decrease in muscle tone
Bradykinesia
decreased amplitude and velocity of voluntary movement
Hypokinesis
decreased motor response especially to a specific stimulus
Differentiate between lesions of the right and left hemispheres in terms of expected behavioral deficits.
demonstrate difficulties in communication and in processing information in a sequential, linear manner. They are frequently described as cautious, anx- ious, and disorganized. This makes them more hesitant when trying new tasks and increases the need for feedback and support. They tend, however, to be realistic in their appraisal of their existing prob- lems.
Differentiate between lesions of the right and left hemispheres in terms of expected behavioral deficits.
demonstrate difficulty in spatial-perceptual tasks and in grasping the whole idea of a task or activity. They are frequently described as quick and impulsive. They tend to overestimate their abilities while acting unaware of their deficits. This lack of insight and concreteness impairs the patient's ability to participate in rehabilitation. Safety is a far greater issue with patients with left hemiplegia, where poor judgment is common. These patients also require a great deal of feedback when learning a new task. The feedback should be focused on slowing down the activity, checking sequential steps and relating it to the whole task. Patients also need to be helped to recognize the consequences and risks of their actions. The patient with left hemiplegia frequently cannot attend to visuospatial cues effectively, especially in a cluttered or crowded environment.
Dysarthria
disorder of the motor component of speech articulation
Hypermetria
overestimation of distance or range needed to accomplish a movement
Hypometria
underestimation of distance or range needed to accomplish a movement
What predictable aspects of normal aging may affect coordinated movement?
• Decreased strength • Slowed reaction time • Decreased range of motion • Postural changes (ROM) • Impaired balance (postural control)
