Neuro Rehab Final
What time is associated with fall risk on a Four Square Step Test?
15 seconds (can use AD with test)
What PNF principle utilizes Successive induction?
Dynamic Reversals (slow reversals)
Pathophysiology of hematomas
Epidural - fx of temporal bone and rupture of meningeal artery subdural- rupture of bridging veins in subdural space subarachnoid-often a result of blood vessels posterior fossa
JFK Coma Recovery Scale
Extended DOC 23 subscales, good for emerging consciousness body structure/function of ICF
Components of Orthotics
Foot plate (full, 3/4 foot) Joint assists (spring) Joint stops (End Range) Straps
Intracranial pressure
normal = 5-15 mmhg aim to keep lower than 20 mmhg
Verticality & LOS Postural Impairments
- Alignment (Posture, WB, ROM) - Sensation - Perceptions
Types of Peripheral Vestibular Hypofunction Issues
- Anything thats not a Disease, TBI, or CVA such as -BPPV, -Vestib neuritis, -lybryinthitis, -acoustic neuroma, -disuse dysequilibrium, -Menier's disease, -perilymphatic fistula
Behavioral and emotional symptoms of a concussion
- Drowsiness - Fatigue/Lethargy - Irritability - Depression - Anxiety - Difficulty falling asleep - Sleeps longer than usual - Difficulty concentrating, remembering - feeling in a fog or dazed
Types of Joints for for AFO's
- Fixed - Locking - Free Swinging - DF Assisted/Stop - PF Assisted/Stop
Reasons to Px a Solid AFO
- Foot clearance - Quad Strength >3/5 - Knee Hyperextension - PF Contractures
Considerations for Orthotic Prescription
- Max Function with Min Bracing -Edema present -Integumentary intact -CLOF (standing, walking, etc...) -Strength Level (3/5 needed to hold joint pos in gravity) -Proprioception/sensation in area -Cognitive/emotional
Reasons to Px an articulating AFO
- More active lifestyle - Adjustable for progression -
Why does postural control get worse with age?
- Muscle fibers change to mix of type 1 and 2 - Skeletal changes - Less peripheral receptors - Overall weaker/slower
What is the short Fullerton Advanced Balance (FAB) Scale?
- Only Top 4 items associated with falls - Score of 9 or less = fall risk
Types Of AFOs
- Rigid - high level of M-L Support - Semi Rigid - M-L walls are cut back - Posterior Leaf Spring - DF Assist from flexible plastic and GRF (Springs)
Sensory Postural Impairments
- Somatosensation - Vision (Diplopia and other impairments) - Vestibular (use and dysfunction)
Cognitive Postural Impairments
-Attention limitations • Sustained focus and/or distractibility • Memory
In general, what are the return to play/return to learn stages?
-Nothing -light practice/aerobic ex -back to school part time/ sport specific -part time school again/non contact drills -full time school/contact practice -fulltime school/back in the game
Biomechanical Postural Impairments
-ROM - Posture (A-P/M-L)
Anticipatory Postural Impairments
-Strength • Force grading • Neural transmission • Motor planning
Reactive Postural Impairments
-Strength and force grading -Sequencing -Neural Transmission -Somatosensory
How does older adults stepping strategy differ from younger adult?
-Takes 1 or more additional steps after the initial stepping reaction -Often a side-step following a forward or backward step n -Multiple side-steps instead of a cross-over step - Leg collisions noted more frequently with lateral stepping
What might cause lateral trunk lean toward less involved side during swing phase
-Using Gluteus Medius to lift affected LE off of the ground. -Weakness of trunk muscles on affected side. -Scoliosis -IT band shortness-hip pain
Knee hyperextension during mid-terminal stance on the more involved side
-Weakness of knee flexors/extensors -Impaired proprioception -Quadriceps spasticity -Accommodation to fixed plantarflexion -Locking knee for stability due to weakness
What are some impairment based interventions for concussion?
-cervical/MSK -Vestibular/oculomotor -exertional -motor function/balance
What are some Dual-task Examination Considerations?
-does one or both tasks suffer -which task is prioritized -are they using posture first strategy
Describe the cognitive demands of postural control and implications for dual-task stability and task performance.
-finite amount of cognitive attentional resources -when reaching our attentional limits one or multiple tasks decrease -reaction times are slowest when postural demands higher -attentional demands increase with balance challenge
Describe the pathophysiology of concussion
-k ions rush out of cell -Ca ions rush into the cell -metabolic dysfunction ensues
Acute Recovery phase of Concussion
0-4 weeks Emphasize: ● Recovery facilitation ● Education ● Reassurance ● Sub-system threshold training ● Nonpharmacological interventions
5 signs of a concussion immediately after injury
1. Altered Mental Status at time of injury. 2. Loss or Decreased LOC <30 mins 3. Memory impairments for events less than 24 hours 4. No Evidence of Intracranial Injury 5. Physical Symptoms i.e. Vestibular, Balance, Weakness, Headache, Visual, Hearing (impairments or sensitivity), Dizziness, Abnormal eye movement, Pupil dilation, Bruising, Slurred speech, tinnitus, Nausea, Vomiting
Sacades - Peripheral or central?
Central
Post-acute recovery phase of concussion
4-12 weeks Referral to interdisciplinary clinic Managing symptoms: ● Sleep Headache ● Mood ● Fatigue ● Memory & attention ● Graduated return to activity
What is the general rehab timeline for a peripheral vestibular hypofunction?
6-8 weeks with daily exercises
HiMAT tool
Activity domain of ICF must be able to walk 20 meters without AD, orthoses are permitted
Which PNF techniques increase Strength?
Agonist Reversals Rhythmic Stabilization (one direction) Slow Reversals (2 directions)
Which PNF pattern focuses on eccentric strength?
Agonist reversals/ Combination of isotonics
Which PNF techniques increase ROM?
Alternating Isometrics Contract Relax Hold Relax Hold Relax Active Motion Rhythmic Initiation
Different APR strategies for Postural Stability
Ankle - Slowly moves COM over Large Distance Hip - Rapidly moves COM over Small Distance Stepping - relocate BOS Reach (and grasp) - add more contact w/support surfaces
What is the Postural Assessment Scale for Stroke used for?
Assessing of balance during stable and changing positions with stroke - lower functional abilities
If your patient begins to describe vertigo what might be some possible causes?
BPPV, UVH, unilateral central lesion affecting the vestibular nuclei, migraine affecting central vestibular pathways
Possible Causes of Dysequilibrium (feeling off balance)
BVH, Chronic UVH, LE Somatosensation loss, Upper brainstem/vest. cortex lesion, Cerebellar and motor pathway lesions
What should you watch out for after a pt acquires their AFO?
Build up wear schedule starting with short time increments Check for skin breakdown Check shoe fit check sock fit
What are some possible causes of dizziness?
Cardiopulmonary Metabolic MSK psychological TIA Migraine Post concussion Vestibular
What Gait Assessment is the FGA a more advanced form of?
DGI (Dynamic Gait Index)
Does ankle strategy go proximal to distal or distal to proximal?
Distal to proximal
Tests, and Treatments for Peripheral Vestibular Hypofunction
HIT - nystagmus towards hypofunction HSN - Fast phase of nystagmus is away from involved side DVA - any nystagmus Txs: Adaption (Gaze Stabilization), Substitution, Habituation, Balance, Mobility
Medial-Lateral Postural Stability Primarily comes from...?
Hip and Trunk diagonal = TFL and RF
Retinal Slip
Image moves off retinal fovea - this is what causes visual blurring
Traumatic Brain Injury
Injury to the brain caused by an external force after birth -birth trauma does not count or internal sources
Difference between Best and Mini Best Balance Assessment
Mini Best Assessment leaves out Biomechanical and Verticality and Stability Limits
Glascow Coma Scale (GCS)
Neurologic assessment of a patient's best verbal response, eye opening, and motor function. less than 9 is severe
Brandt-Daroff Exercises
No longer supported for canalith repositioning May be used for habituation. Looks like sermont
If your patient begins to describe light-headedness what might be some possible causes?
Orthostatic hypotension, hypoglycemia, anxiety, panic disorder
Participation objective, Participation subjective measure (POPS)
Participation domain of ICF Self report measure
Orthotic Materials
Plastic - light and modifiable, no edema Carbon Fiber - light, strong, non-modifiable Steel - strong, heavy Titatium - light, strong, non-modifiable
What factors are associated with poorer outcomes of a BI?
Pre-existing/concurrent medi dal conditions or Post-injury symptoms * These are associated with poorer outcomes
What rancho level should you use a memory book?
Rancho levels 5-6
Second Impact Syndrome
Rapid decrease in consciousness, cranial nerve function, respiratory distress
Which PNF pattern is used to teach a pattern?
Rhythmic Inititiation
Which PNF pattern is used for stability?
Rhythmic Stabilization/Stabilizing Reversals
What is the difference between sensory organization vs. sensory reweighting?
Sensory organization - CAN one reshift the senses used under different task & environmental conditions Sensory reweighting - Reliance on one input increases while utilization of another decreases
What is the FIST test used for?
Sitting Balance
True/False: Symptom severity in initial days following BI is most consistent predictor of recovery rate
True
what is the Fullerton Advanced Balance Scale used for?
Used to assess balance in independent older adults - Score Less than 25 = high fall risk
Difference between vertigo and Oscillopsia
Vertigo is feeling or illusion of movement (person or environment) - Often invoked position or movement Oscillopsia is VISUAL DISTURBANCE where one sees objects oscillating. - Often invoked by busy environment
What are the 6 subtypes of concussion
Vestibular ocular Anxiety/Mood Cervical Post-traumatic Migraine Cognitive/Fatigue
What are the three sensory contributors to balance?
Vestibular, Somatosensory, Vision
Persistent recovery phases of concussion
greater than 12 wks Interdisciplinary team if not already in place Individualized symptom management approach with goal of returning to pre-injury activities
Motion Sensitivity quotient
higher score is worse 31-100 severe
What systolic bp is associated with high mortality?
less than 90
Moss Attention Rating Scale (MARS)
observational rating scale based on rating client for two days some items are reversed or flipped when scored and only validated for rancho 4 or higher
DHI
self report measure higher score=greater sx impact
Community Integration Questionnaire (CIQ)
self report performance of independent activities
Irradiation
spreading of the strength response
Gait Instability Postural Impairments
• A composite • Includes other subsystems • Numerous impairments
perceptual Postural Impairments
• Can include disorders &/or psychosocial perceptions • Verticality disorders • Self-efficacy and fear of falling
Gait - things to think about
•How to set up your environment •What AD to use - hemiwalkers •Other equipment •To stool or not to stool •How to get the patient to learn the correct movement patterns Gait facilitation.pptx slide 2