neuro exam 3

Skilled nursing facility (longer lengths of stay; less aggressive)

-Basic self-care -Mobility -Home management -Community re-entry

Outpatient or home care:

-Basic self-care and mobility tasks -Home management (meal prep, cleaning, laundry) -Community tasks (grocery shopping, banking, going to place of worship, public transportation, leisure) -Work/education -person should be more independent (need less help or supervision most likely)

Acute and inpatient rehab:

-Bathing and dressing -Basic transfers (bed, toilet, shower/tub) -Basic home management if needed (simple meal) (rarely return home independent in these areas given shortened rehab stays) -acute = more severe, don't see the patient as much, I would set goals for 2 weeks max (otherwise refer to home health or SNF) -FIM scoring = see the person physically do these tasks -don't be afraid to ask for help with patient

Collaboration with client:

-Focus of intervention around goals that enable discharge to home, often with family supports -Allows clients to transition to less restrictive environments as quickly as possible -Client-centered -goals need to be appropriate and sound -person needs to be aware of their impairments

INTERVIEW: Contexts and Environments: barriers and supports:

-Physical: home, work, furniture, devices, pets, assistive equipment, etc. -Social: social supports, family, caregivers, social groups, community and financial resources -Cultural: customs, beliefs, activity patterns, behavior standards, societal expectations -Personal: socioeconomic, gender, age, education -Virtual: email, text, other

INTERVIEW: Client's perspective of current functioning:

-What client views as main problems resulting from CVA -What goal areas are relevant for client

Fugl-Meyer Assessment

-post-stroke -not generalizable (not functional, basic ROM and function assessed) -pain measured -strength measured -etc.

OBSERVATIONS GENERAL CONSIDERATIONS FOR EVALUATION OF THE TRUNK

1. (as appropriate), the client should be undressed to make it easier to observe movements during functional tasks 2. Evaluate the trunk in a variety of postures that coincide with various ADLs. Trunk adjustments are task specific! Supine Sidelying Sitting Standing 3. Evaluate while client is performing tasks/activities -start off with bed mobility --> sitting --> standing -how much assistance do they need? Are they aware of their effected side? Can they tolerate weight bearing on their affected side? Then move to occupation-based assessments

To be labeled a CVA- how long must the neurological deficits persist?

24 hours

Wolf Motor Function Test interpretation

A higher score indicates better functioning of upper extremities. The final time score is a mean time of all individual timed tasks that are performed. The results, for the therapist, help in determining a before (baseline) and after measurement relative to the client's scores

BOT 2 population

Age range: 4-21.11 Used in pediatric and adolescent rehabilitation.

How does the WHO define stroke?

An acute neurological dysfunction of vascular origin with symptoms and signs corresponding to the involvement of focal areas of the brain

Common Malalignments of the shoulders

Asymmetrical height, Unilateral retraction

Common Malalignments of the pelvis

Asymmetrical weight-bearing; Posterior pelvic tilt; Unilateral retraction

EVALUATING TRUNK FLEXION (NORMAL MOVEMENT) (slide 13)

Begins in neutral and moves into trunk extension - moves shoulders behind hips slowly -Muscle Group Agonist/Contraction: Trunk flexors/eccentric Begins in extension and moves shoulders forward to neutral -Muscle Group Agonist/Contraction: Trunk flexors/concentric Moves from neutral upright position to lumbar flexion posture (Posterior Pelvic Tilt) -Muscle Group Agonist/Contraction: Initiated by lower trunk and pelvis, then continued by trunk flexors -concentric (also could be achieved by relaxation of trunk extensor) Lifts LE into hip flexion, and holds position -Muscle Group Agonist/Contraction: Trunk flexors/eccentric Supine to sit (photo) -Muscle Group Agonist/Contraction: Trunk flexors/concentric

EVALUATING TRUNK EXTENSION NORMAL MOVEMENT (slide 14) (bridging)

Begins in posterior pelvic tilt and flexed spine and moves to neutral upright position with neutral or slight anterior pelvic tilt -Muscle Group/Contraction: Trunk extensors: concentric From neutral position, leans forward while keeping shoulders in front of hips -Muscle Group/Contraction: Trunk extensors: eccentric From position B, returns to upright position -Muscle Group/Contraction: Trunk extensors: concentric Bridging in supine -Muscle Group/Contraction: Trunk and hip extensors, concentric

THERAPEUTIC EXERCISE

CONVENTIONAL OT AND PT PLUS TRUNK EXERCISES IMPROVE SITTING BALANCE AND SELECTIVE TRUNK MOVEMENTS AND POSITIVE EFFECT ON SELECTIVE PERFORMANCE OF LATERAL FLEXION •SUPINE EXERCISES: anterior/posterior pelvic movements, bridging, trunk rotation •SITTING: -flexion and extension of trunk without moving the trunk forward or backward; -flexion/extension of lumber spine, -flexion/extension of hips with trunk extended, -lateral flexion of he trunk initiated from the shoulder and -pelvic girdle, upward and lower trunk rotation, -scooting forward and backward

BOT 2 position and materials

Can be done in any quiet setting as long as there is a table and chair for the subject to sit in. the examiner's manual, 25 examinee booklets, a scoring transparency, an administration easel, 25 record forms, 15 blocks, 50 cards, a pegboard, 20 pennies, 2 red pencils, a shuttle block, a target, a balance beam, a box, a knee pad, 30 pegs, a penny pad, scissors, string, a tennis ball, a stopwatch, tape measure, table, and two chairs.

Wolf Motor Function Test position and materials

Dots on the floor should indicate where the chair should be positioned for a person approximately 5'8"' in height. There are three different chair positions that can be designated by different color dots. One of the following chair positions will be used for each of the task activities: -Chair Position -Testing can be done in a rehabilitation center for clients in treatment. Cardboard box 10-inches (25.4 cm.) in height. This represents approximate shoulder height for the average adult. An 8-inch (20.3 cm.) and 6-inch (15.2 cm.) box should also be available for shorter individuals. One pound cuff weight with velcro strap, 1-20 pound cuff weight with removable inserts, unopened 12 oz soft drink can, 7 inch pencil with 6 flat sides, paper clip, 3 standard checkers, index cards, standard dynamometer, lock and key secured to a board placed at 45 degree angle, standard dish towel 25-inch (63.5 cm.) x 15-inch (38.10 cm.), plastic or wicker tote basket with handle, stopwatch to time, straight back chair, desk table of standard height, template to be taped to desk, talcum/baby powder

Action Research Arm Test (ARAT) population

For individuals with chronic and acute stroke, multiple sclerosis, traumatic brain injury, and Parkinson's. This test is administered to individuals 13 years of age or older.

Common Malalignments of the LE

Hips toward extension (posterior pelvic tilt, Hip adduction, feet not equally weight-bearing

FOCUS

Initially on role performance and occupational performance tasks because they are the goals of motor behavior. Understanding the roles that a person wants, needs, or is expected to perform and the tasks needed to fulfill those roles enables OT to plan meaningful and motivating intervention programs. OT uses task analysis to identify which subsystem of person or environment is limiting performance -May need to evaluate specific subsystems of person or environment. -OT should be at the participation and activity level rather than impairment level -engaging the client in their treatment -look at client's perception -what are their roles? -occupation based more meaningful that activity based -use task analysis and identify subsystems (what is limiting this person, may be different for each environment they are in)

ischemic stroke

Injury results from tissue anoxia caused by the disruption of cerebral blood flow. -Embolic Stroke -Thrombotic Stroke

ABILHAND description

Instruction is given at the beginning of the test. The examiner explains that the client will be asked to rate the level of difficulty of different tasks. They should be considering these tasks with no human help, with any compensatory strategies they may use, and regardless of the limb actually used to complete the task. The response options are impossible, difficult, easy, and question mark. Impossible means that without help, the individual cannot complete the task. Difficult means that the individual can perform the activity without help, but they struggle. Easy means that the individual can perform the activity without help and without difficulty. Question mark can be used when the individual has never performed the activity or is unsure about the level of difficulty the task takes. The examiner explains this rating scale to the client and assists the client in answering the first 5 questions to give them a feel for the scale. After this, the examiner gives the client the opportunity to complete the rest of the assessment and can repeat the instructions as needed. The number of questions on the questionnaire vary depending on the diagnosis an individual has. The chronic stroke form is 23 questions, rheumatoid arthritis is 27, systemic sclerosis is 26, and neuromuscular disorders is 22. We will be using the chronic stroke form for this assignment. Scoring is done with an online analysis on the ABILHAND website. Examinee responses are inputted into the website and then a Rasch analysis is performed

process

Interview v Skilled Observation v Standardized Assessments

Which is most common stroke?

Ischemic

EVALUATING LATERAL TRUNK FLEXION (slide 15)

Lateral flexion initiated with UPPER trunk -Muscle Group Agonist/Contraction: Eccentric contraction of side of ELONGATION (left) Return to midline from lateral flexion -Muscle Group Agonist/Contraction: Left lateral trunk flexors: Concentric Lateral flexion initiated with LOWER trunk and pelvis (elevated with weight shift) -Muscle Group Agonist/Contraction: Right lateral flexors concentric -Muscle Group Agonist/Contraction: Trunk elongates on LEFT (side of weight bearing) -

Common Malalignments of the rib cage

Lateral title, unilateral retraction

EVALUATING TRUNK ROTATION EXTENSION WITH ROTATION (slide 17)

Lower trunk and pelvis initiate a forward movement on one side while upper trunk remains stable (scooting forward side to side on edge of bed or chair) -Muscle group/contraction: Trunk extensors - concentric Reaching behind at shoulder level -initiated at upper trunk (reaching for seatbelt) -Muscle group/contraction: Trunk extensors - concentric, Obliques - eccentric

DISSOCIATION OF MOVEMENT: Clients poststroke may have nonfluid movements and move their body segments as one unit

May be caused by -soft-tissue tightness -contracture -efforts by the trunk to decrease the degrees of freedom (number of joints available for movement) in the trunk when someone's engaged in functional activities

Postural Assessment Scale for Stroke Patients (PASS) interpretation

PASS scores can indicate the client's ability to sit, stand, or lay in different positions. It also allows us to assess and monitor the ability to maintain a position and transition to another. Assessing these tasks assists in determining the level of balance and postural control which can help predict the ability of ambulation in stroke patients. A higher score indicates better balance, with 36 being the highest score. Items 1-5 assess "maintaining posture" and items 6-12 assess "changing posture".

THEN, UNDERSTAND MUSCLE CONTRACTIONS AS THESE RELATE TO MOVEMENT

PROGRAVITY MOVEMENT: Agonist is eccentrically contracting to control movement ANTIGRAVITY MOVEMENT: Agonist is concentrically contracting to control movement HOLDING: Muscles surrounding joint are isometrically contracting -weight shift assessment = functional reach test

Postural Assessment Scale for Stroke Patients (PASS) position and materials

Participants can be measured for balance in lying, sitting and standing. Paper, pencil, stopwatch, 50cm high examination table

ASSESSMENTS

Person: (client factors, performance skills and patterns) -Role check list; COPM -Occupational Performance Measures (focus on these more in OP 1,2, 3) -Cognition/Vision/Perception: focus on these in Sensory Cognition course -Psychosocial: focus on these in Psychosocial course -Sensorimotor - will identify these as we progress through course -grade the task -does it make sense to be doing what we are doing -ex: asking about steps outside and inside the home because this person lives at home alone and had a right CVA -identify the person's prior and current abilities

Interview: AOTA OCCUPATIONAL PROFILE

Prior medical history Prior lifestyle (occupational history and performance patterns: Life Roles and Social Participation: - Identify past roles and whether they can be maintained. - Determine how future roles will be balanced Routines (typical daily routine at home; typical day at work): time wakes up, bathe (type of bath), rest breaks or pace daily activities throughout day? Household chores? Occupational history/Prior functional status: occupational performance with ADLS, IADLs, etc; -Prior status - occupations in which client was successful, did client need assistance? Functional performance in the community? -What does the client like to do? Need to do? Or expected to do? -general outline (facility you work at may have their own profile outline) -daily routine specific to them (not everyone showers every day, some get bedside baths = educate caregivers) -roles change with life events (i.e., stroke) -some people use adaptive equipment to assist them in their occupations and functioning

Common Malalignments of the head/neck

Protraction, flexion to week, rotation away from weak side

Common Malalignments of the vertebral column

Scoliosis, Loss of lumbar curve, Increases thoracic kyphosis, shortening on one side; elongation on other

What are other dysfunctions that may occur as a result of a stroke?

Sensory disturbances, cognitive and perceptual dysfunction, visual disturbances, personality and intellectual changes, and complex range of speech and associated language disorders

ABILHAND position and materials

Since it is a self-report questionnaire, individuals can take this questionnaire in hospitals, their homes, and health centers. A quiet environment may be preferred, but the individual may take the questionnaire in any setting.

HOW TO GRADE ACTIVITIES

Sitting Surface: Firm and stable surface Full thigh support --> Cushioned or unstable surface Partial thigh support Object: Within arm's reach --> Beyond arm's reach Use of arms: Reach with one arm ---> Reach with both arms External Support: Maximum via therapist or surface --> None Prediction: Predictable (stationery object) --> Unpredictable (moving object - ball)

EVALUATING TRUNK ROTATION FLEXION WITH ROTATION (slide 16)

Sitting upright, reach across body toward floor -Muscle group/contraction: Obliques - concentric, Back extensors - eccentric Backward shift with the lower trunk and pelvis to scoot backwards in sitting- while shifting to one side and rotating to the opposite side -Muscle group/contraction: Obliques - concentric, Back extensors - eccentric Supine and initiates a segmental roll by lifting shoulders toward the opposite side of body -Muscle group/contraction: Obliques - concentric -crossing midline -backward shift = booty scoot (be mindful of skin integrity)

Postural Assessment Scale for Stroke Patients (PASS) population

Stroke patients during the first three months after the stroke, adults ages 18-64 and 65+

NEED TO UNDERSTAND NORMAL MOVEMENT FIRST

TRUNK EXTENSION: corresponds with anterior pelvic tilt TRUNK FLEXION: corresponds with posterior pelvic tilt Weight shift follows the direction of the reach

SKILLED OBSERVATIONS

Task Selection and analysis: -What client factors, performance skills and patterns, or contexts and activity demands limit or enhance occupational performance?

Action Research Arm Test (ARAT) interpretation

The ARAT score sheet is based on a four-point rating scale, ranging from 0-3. A score of 0 means "can perform no part of the test", a score of 1 means "performs test partially", a score of 2 means "completes the test but takes abnormally long or has great difficulty", and a score of 3 means "performs test normally". The maximum score you can get for this test is 57 points (meaning that they performed the test with no issues), given that you score a 3 on the first item of each of the four subsets. For example, for the "grasp" subset, there are 6 items. If the participant gets a 3 on the first item, then they will automatically be awarded a 3 for all 6 tasks (equaling 18). This method continues for each subset and the total is added at the end. How high or low the score is in the end will determine the participant's need for intervention.

BOT 2 interpretation

The BOT-2 uses a scale score to tell how far an examinee's point score is from the mean point score of examinee's of the same age, and these scores can range from 1 to 35. A difference between two scale scores represents the same amount of difference in ability regardless of where the score falls on the scale. The standard scores describe an examinee's level of proficiency on the four motor-area composites, and this tells how far an examinee's score is from the mean of scores of the same age. The interpretative steps include describing overall the motor proficiency, describe the motor-area composite and subtest scores, interpret differences among motor-area composites, and then interpret differences among subtests.

Postural Assessment Scale for Stroke Patients (PASS) description

The PASS is a performance measure of 12 tasks assessing balance a range of difficulty levels in lying, sitting and standing positions. The items are rated on a scale 1-4 with relevant descriptions for each task. The tasks assess postural control and changing of posture. An example of a task is standing without support. The response can range from "cannot stand with support - 0" to "can stand with support of one hand - 3."

Peabody Developmental Motor Scales - 2 (PDMS-2) position and materials

The PDMS-2 should be administered in a quiet, comfortable, and non-distracting environment. There should be plenty of room for the child to move around and perform all designated gross motor activities as well as a table and chair to perform the fine motor activities. the Examiner's Manual for scoring, the Profile/Summary form, the Examiner Record booklet, and the Guide to Item Administration book. The abbreviated instructions in the Examiner Record booklet can be used once the therapist is very familiar with the testing procedures. Based on assessment results, the Motor Activities Program book can be used to facilitate treatment according to their current developmental skill level. The Peabody Motor Development chart gives the examiner a reference for age averages pertaining to motor skills. Finally, the examiner needs the test manipulatives. Items included in the test kit are; 1 black shoelace, 6 square beads, 12 cubes, 1 bottle with screw-on cap, 1 large button strip, 1 pegboard, 3 pegs, 1 foam board, 3 forms, 1 lacing card, 1 measuring tape, 1 roll of 2 in. wide masking tape, blackline masters, and 3 shape cards. Items not included in the kit; rattle, soft plush toy, small toy on string, empty soft drink can, 8 in. ball, tennis ball, cup, spoon, washcloth, 10-15 sheets of paper (81/2 x 11 in.), pencils/crayons/markers, blunt scissors, large pull toy, book with thick cover pages, food pellets, 4-5 ft. of heavy string or rope, stairs with 7 in. raise, stopwatch, mat, and sturdy object (16-21 in. high). The kit can be purchased online at https://www.pearsonassessments.com.

ABILHAND interpretation

The Rasch data analysis outputs a linear measure. The solid red line is where the client is functioning, and the dotted red line is the 95% confidence interval. The further to the right the straight line, the better functioning the individual is. The data analysis shows specific tasks the individual has difficulty with. Scores that are circled in red on the data analysis are considered atypical. Norms are also available. Areas that the individual marks as difficult or impossible gives the therapist ideas of what to work on in intervention

Wolf Motor Function Test description

The Wolf Motor Function Test (WMFT) quantifies upper extremity (UE) motor ability through timed and functional tasks. When administering the WMFT, the examiner should test the less-affected UE followed by the most affected side.Mood and energy level will both be assessed. Items should be performed as quickly as possible; a maximum of 120 s per task is allowed. The first 6 items involve timed functional tasks, items 7-14 are measures of strength, and the remaining 9 items consist of analyzing movement quality when completing various tasks. There are 2 different scores: the WMFT -Time (time required to complete the tasks) and WMFT -FAS (Functional Ability Scale, where a score of 6 points is used to assess the functional capacity of each task: 0 indicating that the patient cannot attempt the task, and 5 where the movement seems normal

Wolf Motor Function Test population

The assessment is performed on clients who have survived from a traumatic brain injury (TBI) and/or cerebrovascular accident (CVA). The original test was designed for higher functioning patients, and the modified versions evaluate patients with moderate to severe motor deficits

Peabody Developmental Motor Scales - 2 (PDMS-2) interpretation

The child's raw scores, percentiles, age equivalents, and standard scores for each subtest are recorded on the form. The FMQ, GMQ, and the Total Motor Quotients are recorded as the total of each composite. The age equivalent scores give the child a "motor age" for each subtest which can be compared to where most children of a chronological age typically score. The percentiles also give the therapist and family an idea of how the child's motor abilities compare to the distribution of the relative population. The standard scores and quotient scores are ranked according to a scale as very superior, superior, above average, average, below average, poor, and very poor. All of this information as well as clinical observations can be used to determine the child's current functioning compared to the normative population to guide intervention.

Action Research Arm Test (ARAT) position and materials

The participant will need to be seated in an armless chair, at a table, in a well-lit room. Forearms should be pronated with their palms resting on the table at either side of the tool kit. For the last task, the gross motor portion, the participant will sit away from the table, palms on their lap, and will then be instructed to place their hands behind their head. the ARAT scoring sheet and a pencil. You will also need the ARAT tool kit that contains wooden blocks, a cricket ball, 2 cups, marbles, ball bearings, a tin lid, washers, bolts, a sharpening stone, tubes, and a plank. A table and a chair without armrests is also needed. The ARAT tool kit itself acts as a tool/platform as well during the test.

BOT 2 purpose

The purpose is to provide a comprehensive overview of fine and gross motor skills in children and young adults within school age- range.

ABILHAND purpose

The purpose of ABILHAND is to measure bimanual ability as perceived by the patient. It is measuring a person's perception of their ability to manage daily activities that require use of the upper limbs.

Peabody Developmental Motor Scales - 2 (PDMS-2) purpose

The purpose of the PDMS-2 is to measure children's interrelated motor abilities. The five principle uses of this tool are to estimate the child's motor competence relative to their peers, determine their Gross Motor Quotient (GMQ) and Fine Motor Quotient (FMQ), attain qualitative and quantitative measurements for intervention, and evaluate their progress. It can also be used to determine the role of motor ability in academic success, investigate how effective various motor interventions may be, and serve as a research tool for various populations.

Wolf Motor Function Test purpose

The test is designed to assess and characterize the motor ability and status of chronic higher functioning stroke or traumatic brain injury patients with moderate to severe upper extremity motor deficits

ABILHAND population

This instrument is intended for individuals with upper limb impairments or bimanual difficulties. It was originally developed for individuals with rheumatoid arthritis and chronic stroke. ABILHAND-KIDS is for ages 6-17. ABILHAND is for adults ages 18 and up. Currently, there are different testing forms with individuals with chronic stroke, rheumatoid arthritis, systemic sclerosis, and neuromuscular disorders

Action Research Arm Test (ARAT) description

This is a 19 item test divided into 4 subsets (grasp, grip, pinch, and gross motor). Each subset is based on a four-point rating scale. The items are ordered from difficult to easy for each subset. If the patient receives a score of 3 on the first item, they can skip the rest of that subset and move onto the next. If they score less than a 3 on the first item, they must move onto the second item for that same subset. If they score a 0 on that second item, they are unlikely to be able to complete the rest of the items and are credited with a 0. One example of the many tasks from the test is to have the participant grasp a 10cm wooden block and place it on an elevated surface.

Postural Assessment Scale for Stroke Patients (PASS) purpose

This measure is used to assess and monitor postural control after a stroke. It has 12 four level items of a range of difficulties for assessing ability to maintain or change a given lying, sitting, or standing posture.

Peabody Developmental Motor Scales - 2 (PDMS-2) population

This tool can be used for children birth- 5 years old. The reflex subset is for ages birth-11 months and the object hand manipulation subset is for ages 12 months and older. This tool is often used for children with cerebral palsy and other disabilities in a pediatric rehabilitation setting. The population used for standardization was 2,003 children from 46 states in the United States from 1997-1998.

Task Oriented Approach: Evaluation Framework

Top Down Approach

EVALUATION STANDARDIZED ASSESSMENTS

Trunk Control Test: roll from supine to weak side; roll from supine to strong side, sitting up from supine, sitting on edge of bed for 30 seconds •0 - unable with assistance •12 - able to perform but abnormal manner •25 - able to perform normally •Postural Assessment Scale for Stroke Patients •Fugl Meyer Assessment

Handling

USE HANDLING WITHIN CONTEXT OF FUNCTIONAL TASK •Client must be aware of the goal associated with handling •Grade handling to allow client to perform as much of the movement pattern as possible •Use early in intervention (motor learning)

What are the primary results of a stroke?

Upper motor neuron dysfunction that produces hemiplegia or paralysis of one side of the body

DISSOCIATION OF MOVEMENT: Normal control in any body part requires the ability to dissociate different parts of the body

Upper trunk rotation with lower trunk stability (reaching for toilet paper) Counter-rotation of trunk while ambulating Upper trunk rotation with concurrent lower lateral flexion when reaching with right hand for phone on left (crossing midline) -counter-rotation = as you move one side the other twists -will do a lot of compensating (they think it is normal)

Common Malalignments of the UE

Use of stronger extremity as postural support, too little or too much activity in involved UE

Evaluation of the Adult with Hemiplegia

VVV

EVALUATING TRUNK CONTROL AND MOVEMENT

VVVV

EXAMPLES OF TRUNK CONTROL & ADLS

WHAT TYPE OF TRUNK MOVEMENTS ARE NEEDED TO PERFORM: -UE DRESSING -LE DRESSING (SEATED) -BRIDGING -SCOOTING -TOILETING -BATHING (SEATED) -GROOMING lab handout

Define stroke

a complex dysfunction caused by a lesion in the brain

BOT 2 description

assesses proficiency in four motor-area composites: fine manual control, manual coordination, body coordination, and strength and agility. There are two subtests for each motor area which include fine motor precision, fine motor integration, manual dexterity, bilateral coordination, balance, running speed and agility, upper-limb coordination, and strength. There are four administration options: the complete form, the short form, select composites, or select subtests. The BOT-2 record form is used for scoring, and the examinee's raw score should be recorded in the corresponding box provided in the raw score column. Each raw score is then converted into a point score using the conversion table corresponding to the item. The subtest point score is obtained by adding the point scores of the individual items that make up that subtest. Transfer all of the subtest total point scores to the lines on the cover page and then look at the norm tables. Norms can be chosen based on chronological age as well as either combined (both male & female) or sex-specific. The sum of the scale scores of the subtests within each motor-area composite are used to obtain the standard score and percentile rank.

Balance between remediation and compensation influenced by:

client prognosis for recovery, discharge environment (physical and caregiver availability), timeframe therapist has to work with client.

Peabody Developmental Motor Scales - 2 (PDMS-2) description

contains 6 subtests. The reflex subset, used for children from birth-11months or with neurological disabilities, contains 8 items to assess the child's automatic reactions to environmental stimuli. The stationary subset contains 30 items that measure the child's ability to maintain their center of gravity and retain their equilibrium. The locomotion subset contains 89 items that measure their ability to move. The actions measured in this subset are crawling, walking, running, hopping, and jumping forward. The object manipulation subset, used for children 12 months and older, contains 24 items that measure their ability to handle and control balls. The grasping subset contains 26 items to measure the child's motor ability of their hands. The visual-motor integration subset measures the child's complex eye-hand coordination performance and visual perceptual skills. The child's age dictates the starting point for testing. Each item is scored on a scale of 2 (mastered), 1 (does not fully meet criteria), or 0 (no attempt). A basal level is established when a child scores 2 on 3 items in a row. If the child does not score a 2, 3 times in a row, the examiner should work backwards to achieve the Basal level. A ceiling level is established when the child scores a 0, 3 times in a row after determining the basal level. Testing is complete when a ceiling level is established. The results of the subsets generate composites; Gross Motor Quotient (reflexes, stationary, locomotion, object manipulation), Fine Motor Quotient (grasping, visual-motor integration), and Total Motor Quotient (gross and Fine Motor Quotient for overall motor abilities). The child's interest and understanding of the instruction should be recorded. There is an optional online scoring and report system that can be purchased through Pro-Ed international publisher.

DISSOCIATION OF MOVEMENT: Joint movements require dissociation in order to

execute skilled movements

Non-Modifiable risk factors of stroke

genetic factors, diabetes (type I), age, race, heredity, gender

OT should be at the participation and activity level rather than

impairment level (body functions and structures) -theory supports us as a profession (essential) -visual model of the top-down approach (slide 3)

OBSERVATIONS: FRONT, SIDE, LATERALLY

midline symmetry can be seen in each of these angles (great picture on slide 12

POSTURAL MALALIGNMENTS AND CAUSES

page 366 Gillen

Focus on client independence

return to baseline

DISSOCIATION OF MOVEMENT: dissociate means

separate, or disconnect

TRUNK MOVEMENTS AND WEIGHT SHIFTING DURING REACHING ACTIVITIES(LUE HEMIPLEGIA)

slides 18-19 -tossing a ball -warm-up activity usually (preparatory for occupational tasks and engagement, ROM and stretching)

Modifiable risk factors of stroke

smoking, lifestyle (diet, exercise, stress), hypertension, cardiac diseases, diabetes, drug or alcohol abuse

Action Research Arm Test (ARAT) purpose

to assess specific changes in upper limb functioning in individuals who have experienced a stroke or cortical damage resulting in hemiplegia. It looks at the client's ability to handle objects that differ in size, weight, and shape.

•3 common principles of pelvic and trunk correspondence of movement we need to address when assessing the trunk

•1. Trunk extension corresponds with anterior pelvic tilt •2. Trunk flexion corresponds with posterior pelvic tilt •3. Weight shift follows the direction of the reach

TRUNK CONTROL AND ADLS

•A clear relationship between the loss of trunk control and the loss of functional independence •Trunk control is a prerequisite for the control of more complex limb activities •Predictive value of trunk control on ADL performance - early assessment and management of trunk control is recommended •Trunk flexion and extension muscle weakness can interfere with balance, stability, and function •Measures of trunk performance are significantly related to values of balance, gait, and functional ability -OT is very broad

EVALUATION INTERVIEW

•Determine client's insights into their trunk malalignments and ability to perceive and assume midline Gain insight into client's ability to make accurate observations about their postural dysfunction •Risk of falls? (perceived ability is greater than actual) •Reluctant to attempt tasks with greater demands? (fear of falling) -helpful to use a mirror sometimes, so the client can see themselves and make more accurate observations

Things to consider

•How pelvic, trunk, and weight shift adjustments are impacting different UE reach patterns •Loss of trunk control is very common in clients who have had a stroke •Trunk control impairments include weakness, loss of stability, stiffness, and loss of proprioception -always want to work proximal to distal (trunk is the most proximal)

MAINTAINING OR INCREASING TRUNK ROM THROUGH MOBILIZATION AND MOVEMENT

•Lose ability to shift weight and make postural adjustments •Common to demonstrate static trunk posture (reaction to gravity) •Prolonged immobilization can result in loss of soft-tissue elasticity, joint play, and function •Promote awareness of trunk mobility and movement patterns to that maintain or increase trunk ROM

TREATMENT TECHNIQUES TO ENHANCE TRUNK CONTROL DURING TASK PERFORMANCE

•Observe patient anteriorly, posteriorly, and laterally to detect deviations from normal alignment (Davis materials)

ASSUMING AN APPROPRIATE STARTING POSTURE

•Pelvis in neutral to anterior tilt •Equal weight bearing on both ischial tuberosities •Trunk erect and midline with appropriate spinal curves •Shoulders symmetrical and over the hips •Head/neck neutral •Hips slightly above the level of the knees •Knees in line with hips •Feet equally weight-bearing and underneath knees

WHAT OT DOES

•Physically and verbally cue client to assume an appropriate starting position •Encourage client to FEEL the DIFFERENCE - should be able to assume position automatically •May be helpful to demonstrate the effect of a slumped position on reaching •Use of mirrors should b used with caution •Therapist should be positioned in front of patient to correct posture- mimick/demonstrate movement or verbal cues "Keep shoulders in line with mine" "Keep your forehead at the same level as mine" •Activities that encourage rotation and lateral flexion to gain midline control are best

ENGAGE IN REACHING TASKS TO ELICIT A TRUNK RESPONSE:

•Place object slightly beyond arm's reach - •Setting up activity to control desired response: -Placing items required during the ADL in specific places -Choosing appropriate environment -How far beyond arm span should activity be placed -Characteristics of objects (number, weight, one or 2 hands)

USE VARIOUS POSTURES

•Seated with legs crossed: hemi leg over sound leg - for clients with difficulty controlling lateral flexion and flexion patterns and shifting weight. -Abdominal control is required to prevent posterior loss of balance -Ex. LE dressing, lower body dressing •Sitting in front of a table while bearing weight on both forearms: UEs are point of proximal stability. Practice weight shifting - do before a functional task •Prone on elbows: trunk extension - use with caution (respiratory system, shoulder pain) •Kneeling: use if having trouble with hip and trunk extension - needed to get up from floor •Variations on the degree of hip flexion while seated: knees below hips (Less hip flexion, more Trunk Extension); knees above hips (hip and trunk flexion)

USE ADLS AND MOBILITY TASKS

•Self care, IADLs, and mobility tasks •What are the most problematic movement patterns that occur during the client's daily activities •Use activity analysis to choose appropriate tasks that incorporate the desired patterns and postures. EXAMPLE: problem with lateral flexion and lateral weight shifts -LE dressing -Weight shifting for pressure relief -Scooting -Sidelying to Sitting -Reach for objects positioned above and to the side of the client opposite the side where lateral flexion is desired -Reach for objects on the floor that are on the side of the client -Sit to Stand and Stand to Sit

Evidence of asymmetries:

•Unilateral creases or skin folds •Bony prominences •Muscle atrophy •Position of the head •Height of the shoulders •Position of the pelvis •Position of upper extremities •Position of lower extremities

ADAPTING THE ENVIRONMENT

•Use of outside supports while UEs are engaged in functional tasks (lateral supports, armchairs, pillows/cushions, lap trays) •Rearrange environment - placing items within easy reach (call button, storing dishes on counter rather than in cabinet, grooming items on top of sink) •Adaptive equipment to compensate for poor trunk control - long handled shoe horns, elastic shoe laces, adapted bath brushes, soap on a rope, reachers, tub seats, commodes. •Home modifications: grab bars and bed rails

Trunk control impairments can lead to:

•dysfunction in upper and lower extremity control •increased risk for falls •potential for spinal deformity and contracture •impaired ability to interact with the environment •visual dysfunction resulting from head/neck malalignment •symptoms of dysphagia (due to proximal malalignment) •decreased sitting and standing tolerance, balance, and function •decreased independence in occupational performance and participation -imbalances in trunk change your BOS = increased falls -kyphosis -posterior pelvic tilt can cause them to fall out of their wheelchair -hunched over = impaired body functions (i.e., swallowing) -fatigue more quickly

Postural malalignments can result in:

•soft tissue shortening •loss of ROM •an inability to generate enough force to contract the muscle group in question

Postural malalignments can occur for these reasons:

•unilateral weakness (specifically around the pelvis) •unbalanced skeletal muscle activity •perceptual dysfunction and an inability to perceive midline •soft tissue shortening -with stroke = don't know where their midline is