Neuromuscular Patient Management I - Midterm Exam
Rigid ultra light-weight wheelchair
- Cannot be folded vertically, most has backrest that can fold down. Back height is often lower than standard. Almost all are custom ordered. - Possible disadvantage is reduce shock absorption because the lack of folding points has less shock absorption. - Can come with shocks and material bike is made from can have shock absorbing capabilities. $2000-$6000
Sensory receptors
- Carry AFFERENT information - Once stimulated, they give rise to perception of a specific sensation. - Highly sensitive to the type of stimulus for which they were designed (receptor specificity) - This specificity of nerve fiber sensitivity to a single modality of sensation is called the labeled line principle.
Common hip deviations during the gait cycle: circumduction
- Cause: compensation for weak hip flexors or for inability to shorten leg for limb clearance - Analysis: strength (str) of hip flexors, knee flexors, and ankle DF; ROM in hip and knee flexion, and ankle DF and for abNormal extensor pattern
Common hip deviations during the gait cycle: abduction
- Cause: contracture of glut med or ITB; during swing, could be used to assist with foot clearance - Analysis: hip abductor ROM, other factors necessitation compensation with clearance
Common hip deviations during the gait cycle: adduction
- Cause: hip adductor spasticity/contracture. Excess contralateral pelvic drop - Analysis: examine tone of hip flexors and adductors; mm str of hip abductors
Common hip deviations during the gait cycle: external rotation
- Cause: spasticity or contractures of ER; weakness of IR - Analysis: examine tone, external rotation ROM, str of IR
Common hip deviations during the gait cycle: internal rotation
- Cause: spasticity or contractures of int rotators; weakness of ex rotators; excessive forward rotation of contralateral pelvis - Analysis: tone, IR ROM, str of ER
Lower Level Goals
- Family education regarding positioning, ROM, stimulation. - Demonstrate purposeful movement to commands/sensory stimulation. - Actively participate in treatment session. - Prevent secondary complications. - Pulmonary hygiene
Abnormal observations linked with tasks: Dyssynergia
- Finger to nose - finger to therapist's finger - alternate heel to knee - Toe to examiner's finger
Abnormal observations linked with tasks: Dysdiadochokinesia
- Finger-to-nose - Alternate nose-to-finger - Pronation/supination of the hands - Knee flexion/extension - Walking, alter speed or direction
Combined cortical sensation
- A combination of superficial and deep sensory mechanisms - Exteroceptive + proprioceptive receptors + Intact function of cortical sensory association areas -Stereognosis -Two-point discrimination -Tactile localization -Barognosis -Graphesthesia -Texture recognition -Double simultaneous stimulation
Modality
- A general class of stimulus, determined by the type of energy transmitted by the stimulus and the receptors specialized to sense that energy. -Ex. Vision, hearing, touch, smell, pain, temperature, proprioception
Vision
- A majority of people are dependent on their _____________ for balance If the somatosensation and ____________ are impaired, balance will be markedly impaired and you will have to teach pt. to rely on other systems (vestibular system).
Glasgow Coma Scale (GCS): Scoring
- A patient is assessed against the criteria of the scale, and the resulting points give a patient score between 3 (indicating deep unconsciousness) and 15 • Highest score = 15 • Lowest score = 3
Dorsal Column-Medial Lemniscal Pathway
- AFFERENT - Sensory (bringing in info) - important to having good coordination (perceiving information correctly)
Video Analysis Apps
- Can improve interrater reliability - Can serve as permanent record -examine joint ROM - You can pause the screen - Unrealistic to expect patients to walk enough for us to measure all the variables.
Pressure perception testing
- Fingertip or a double-tipped cotton swab is used to apply a firm pressure on the skin surface. - Firm enough to indent the skin and to stimulate the deep receptors. - Patient indicates "yes" or "now" - Make sure vision is obscured
PT Examination - Control of Movement
- First establish if the patient has isolated control of mvmt - If yes, precede with MMT - If not, describe movement the patient has (do they present with synergy? do they have full ROM? -synergy through full range -able to isolate through ½ of motion and then see evidence of extensor synergy
Sit to stand: Zero Momentum strategy
- Flexing the trunk sufficiently to bring COM within BOS before lift-off - Requires larger LE forces - No Momentum - appropriate with patient with cerebellar pathology
Additional items in wheelchair prescription
- Floor to seat height (will pt. want to propel themselves with their feet?) -Rear -Front - Squeeze/Bucket (seat to backrest angle) - Camber - Push handles - Height adjustable back rest (below scapulas if possible to allow as much arm function as possible) - Canes - Axle plate - Castor housing
Wheelchair types
- Folding - Ultra light weight - Standard - Rigid - Ultra light weight folding -Standard w/c is good for facility use. Available pediatric to bariatric, seat to floor height can be varied, depth not modifiable
Backward reasoning process
- Tends to be utilized by novice or inexperienced clinician - Identifying cues, proposing a hypothesis, gathering supporting data and evaluating hypothesis, and determining appropriate actions
Optic Nerve (CN II)
- Test with Snellen Chart/ETDRS (Early treatment Diabetic Retinopathy study) - Visual Acuity - Visual Fields - Afferent input to Pupillary Light Reflex - Look at the Nerve (Fundoscopic Exam) "PERRLA" - Function: Vision - Test: test visual acuity. 1. Central: eye chart; test each eye separately (covering the other eye); test at distance of 20 feet. 2. Test peripheral vision (visual fields) by confrontation - Possible ABN findings: 1. Blindness, myopia (impaired far vision), presbyopia (impaired near vision) 2. Field defects: homonymous hemianopsia
Sensory integrity
- Testing the ability to interpret and discriminate incoming sensory information -distal/proximal, sharp/dull - Intactness of receptors, CNS processors to produce motor response
Original Ashworth Scale
- Tests resistance to passive movement about a joint with varying degrees of velocity - Scores range from 0-5 - A score of 0 indicates no resistance and 4 indicates rigidity
Dystonia
- hypertonic, disordered tone and involuntary mvmts involving large portions of the body, twisting and writhing motions - sustained involuntary contractions of agonist and antagonists
Dysmetria
- inability to judge the distance or range of a movement. (Hypermetria- overshooting and Hypometria- undershooting) - disorder with the timing of movements, inaccurate amplitude of movement and misplaced force
Dyssynergia
- mvmt performed in a sequence of component parts rather than as a single, smooth activity; decomposition. Lack of coordination btw agonist, antagonist, and other synergic muscles. - decomposition of movements
Cadence
- number of steps/time - can be determined by diving the number of steps (n) taken during the walking trial by the elapsed time (tn) between the first and last heel strikes using the formula c=n/tn - may be measured in centimeters as the number of steps per second - Mean is 113 steps/minute
Abnormal observations linked with tasks: Resting tremor
- observe at rest; limb or jaw mvmts - observe during functional activities (tremor will diminish significantly or disappear with movement)
Abnormal observations linked with tasks: Intention tremor
- observe during functional activities. Tremor will typically increase as target is approached or movement speed increased. - alternate nose to finger - finger to finger - finger to therapist's finger - toe to examiner's finger
Romberg Test
- one of the oldest sensory tests for postural control 1. feet together, EO, unaided 20-30 sec (increased sway or instability with EO the test is over). 2. then EC. If significantly increase in sway compared to EO=positive test *inform patient you are prepared to catch them if they fall----- -a negative test: no change or only minimal worsening with EC -a positive test: pt can stand with EO but shows much more sway or instability with EC. (Sharpened Romberg: feet are placed in tandem (heel-toe) and EO to EC conditions imposed)
Movement and Perception
- sensory/perceptual systems provide information about the state of the body (position in space) *is the individual perceiving their environment correctly so that they can be successful with movement? *impacts movement
Nonfluent aphasia (Broca's, expressive aphasia)
- slowed and hesitant speech with limited vocabulary and impaired syntax - Articulation is labored and word finding difficulties are apparent
Fixation or limb holding
the ability to hold the position of an individual limb or limb segment
Stereognosis
the ability to perceive and recognize the form of an object using cues from texture, size, spatial properties, and temperature
Agility
the ability to rapidly and smoothly initiate, stop, or modify movement while maintaining postural control.
Learning a motor behavior is dependent on
the ability to take in sensory information (from body, environment, and process it)
Patients with decorticate posturing present with
the arms flexed, or bent inward on the chest, the hands are clenched into fists, and the legs extended and feet turned inward
Step length
the distance from the point of heel strike of one extremity to the point of heel strike of the opposite extremity (linear distance between 2 successive pts of contact of the R and L LE. Heel of right to heel of left. Measured in cm or m)
Stride length
the distance from the point of heel strike of one extremity to the point of heel strike of the same extremity (linear distance between 2 successive pts of contact of the same foot. It is measured in cm or m.)
Anterograde amnesia (Post-traumatic amnesia, PTA)
the inability to learn new material acquired after a brain insult
Retrograde amnesia
the inability to remember previous learning acquired prior to a brain insult
Limits of Stability (LOS)
the maximum distance an individual is able or willing to lean in any direction without loss of balance or changing the BOS
Linear velocity
the rate at which a body moves in a straight line
Dynamic weight transfer rate
the rate at which an individual standing in the parallel bars can transfer weight from one extremity to another. Measured in seconds from the first lift-off to the last lift-off
Angular acceleration
the rate of change of the angular velocity of a body with respect to time. Angular acceleration is usually measured in radians per second per second (radians/s²)
Acceleration
the rate of change of velocity with respect to time. Rate of change of velocity of a point posterior to the sacrum. Measured in meters per second per second (m/s²)
Angular velocity
the rate of motion in rotation of a body segment around an axis
Axons of the ventroposterolateral (VPL) nucleus of the thalamus project to
the somatosensory cortex via the internal capsule (anterior spinothalamic, lateral spinothalamic, spinoreticular)
Health
the state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity
Decorticate posturing indicates that
there may be damage to areas including the cerebral hemispheres, the internal capsule, and the thalamus - It may also indicate damage to the midbrain - While it is still an ominous sign of severe brain damage, it is less severe than decerebrate, which indicates more severe damage as the rubrospinal tract and hence, the red nucleus, is also involved indicating lesion lower in the brainstem
Babinski sign should be assessed
when completing reflex assessments
Step width
width of walking base (BOS) is the linear distance between one foot and the opposite foot measured in cm or m
Terminal Swing is __________ of the swing phase
87-100%
10MWT score interpretation
< .4 m/s household ambulators 4-.8 m/s limited community ambulators >.8 m/s community ambulators
A gait speed of _____________ would benefit from PT eval and possible treatment
< 1.9 ft/sec
TUG cut off score for Community Dwelling Frail Older Adults
> 14 associated with high fall risk
TUG cut off score for Post-op hip fracture patients at time of discharge
> 24 predictive of falls within 6 months after hip fracture
TUG cut off score for Frail older adults
> 30 predictive of requiring assistive device for ambulation and being dependent in ADLs
Vestibulospinal tract (medial and lateral)
postural control, coordinated head and eye movements
Location of Brodmann's areas 4 and 6
precentral gyrus (in frontal lobe)
Recovery
re-acquisition of movement skills lost through injury
Alert
Awake and attentive
Mid Swing is __________ of the swing phase
75-87%
Orientation
Awareness of person, place, and time (AND SITUATION) -A&O x 4
Synergy is not the same as
tone
Intensity
weight/sets/reps
Performance
what an individual does In his/her current environment, includes use of assistive devices or personal assistance
Normative Reference Values by Age for the TUG
• 60 - 69 years 8.1 (7.1 - 9.0) • 70 - 79 years 9.2 (8.2 - 10.2) • 80 - 99 years 11.3 (10.0 - 12.7)
Trigeminal Nerve (CN V)
• All modes of Primary Sensation Modalities can be tested •Afferent input for the Corneal Blink Reflex •Normal: "Facial sensation intact in all distributions" • Motor Component •muscles of mastication Sensory: face Sensory: cornea Test: Test pain, light touch sensations: forehead, cheeks, jaw (eyes closed) Test: test corneal reflex; touch lightly with wisp of cotton - AbN: Loss of facial sensations, numbness with lesion, trigger area with trigeminal neuralgia - AbN: loss of corneal reflex ipsilaterally (blinking in response to corneal touch) - Motor: muscles of mastication - Test: palpate temporal and masseter mm, observe spontaneous mvmts, have pt clench teeth, hold against resistance - AbN: Weakness, wasting of mm, when opened, deviation of jaw to ipsilateral side Sensory of face (sharp-dull discrimination, light touch); open and close jaw against resistance; jaw jerk reflex
The nonequilibrium coordination exam focuses on movement capabilities in several main areas:
• Alternate or reciprocal motion • Movement composition, or synergy • Movement accuracy • Fixation or limb holding ***Difficulty level increases from: 1) Unilateral 2) Bilateral symmetrical 3) Bilateral asymmetrical 4) Multilimb tasks ---difficultly is also increased by adding increased challenges to balance
Neuro examination: integumentary
• Any surgical incisions • Lines/Tubes • Lacerations/Bruising from injury • Assess areas of pressure for ulcers or potential areas of breakdown **Assess need for positioning schedule or skin protection i.e. elbow/heel protectors, multi-podus boots, cushions for OOB activity *Especially relevant in patient with impaired cognition, or impaired motor control
A GCS < 8 Evaluation will focus more on:
• Arousal • Response to stimuli • Ability to follow commands • ROM/Tone • Spontaneous Movement
Neuro examination: cognition
• Arousal Level (alert, awake) • Response to Stimuli (Auditory, Visual, Olfactory, etc.) • Ability to follow commands (One step, two step) • Orientation (name, date, place, and situation) • Ability to retain information (short term memory, remember 3 words, carryover with remembering precautions) • Attention span (how much cuing is needed to stay on task?) • Safety Awareness/Insight into deficits ***This will impact your treatment focus as well as a patient's ability to progress toward goals
Spinal pathways: Doral Column-Medial Lemniscal System
• Discriminative sensations (stereognosis, 2-pt discrim, fine gradations of intensity); precise localization, high degree spacial orientation • Fast-conducting fibers of large diameter with greater myelination • Discriminative touch and pressure, vibration, movement, position sense, and awareness of joints at rest - Located on the skin, joints, tendons: specialized mechanoreceptor
Motor skills
• acquired by the CNS/are learned through interaction and exploration of the environment
Motor program
• an abstract representation that, when initiated, results in the production of a coordinated movement sequence -ex. walking down the stairs
Motor Plan (complex motor program)
• an idea or plan for purposeful movement that is made up of several component motor programs
Hypotonia/flaccidity
• decreased or absent muscular tone. Resistance to passive mvmt is diminished, stretch reflexes are dampened, limbs are floppy, absent muscular tone
Dysarthria
• disorder of speech articulation - Speech errors, difficulties with timing, vocal quality, pitch, volume, breath control - Scanning speech, Similar to limb control deficits, the primary impairment of speech may be related to the planning and prediction of movements rather than the execution of speech components directly.
Lower motor neuron syndrome (LMN)
• from lesions that affect the anterior horn cell and peripheral nerve • Decreased or absent tone • decreased or absent reflexes (areflexia) due to interuption og the efferent (motor) limb of the reflex arc • paresis (weakness) or paralysis • muscle fasciculations and fibrillations with denervation • neurogenic atrophy
Reflex
• involuntary, predictable, specific response to a stimulus dependent on an intact reflex arc
Motor Memory (procedural memory)
• involves the recall of motor programs or subroutines
Spasticity
• motor disorder or abnormal muscle tone (type of hypertonicity) characterized by velocity-dependent ↑ in muscle tone with ↑ resistance to passive stretch • The larger and quicker the stretch, the stronger the resistance -this is NOT abnormal posturing or muscle spasm - one component of the upper motor neuron syndrome - It is used to describe: (a) hyperactive stretch reflexes, (b) abnormal posturing of the limbs, (c) excessive coactivation of antagonist muscles, (d) associated movements, (e) clonus, and (f) stereotyped movement synergies. - used to describe many abnormal behaviors often seen in patients with CNS pathology
Emerging into a vegetative state
• return of irregular sleep/wake cycles and normalization of so-called vegetative functions (respiration, digestion, blood pressure control) • Correct term is "minimally conscious state" -Patient may be aroused, but remains unaware of his or her environment
Spinal pathways: Anterolateral Spinothalamic
• self protective reactions • Slow-conducting, small diameter, (some) unmyelinated fibers - Nondiscriminative, poor spatial orientation • Thermal and nociceptive, pain, temp, crude localization, tickle, itch, sexual sensation - originates in the dorsal roots, immediately cross and ascend up the spinal cord through the medulla, pons, and midbrain to the ventroposterolateral (VPL) nucleus of the thalamus - Located on the skin: mechano, thermo, nociceptors
Fluent Aphasia (Wernicke's, receptive, sensory aphasia)
• speech that flows smoothly but contains errors, neologisms, paraphasias, and cicumlocutions - traditionally associated with neurological damage to (Brodmann area 22, in the posterior part of the superior temporal gyrus of the dominant hemisphere) - can speak with normal grammar, syntax, rate, intonation, and stress, but they are unable to understand language in its written or spoken form
Deep Tendon Reflexes (DTR)
• stimulation of the stretch-sensitive IA afferents of the neuromuscular spindle producing muscle contraction via a monosynaptic pathway • Testing: tap sharply over the muscle tendon, the muscle is positioned in midrange and patient must relax
Motor control
• the ability to regulate or direct the mechanisms essential to movement -evolves from a set of neural, physical and behavioral processes that govern posture and movement
Clasp-knife response
• the initial high resistance (spastic catch) followed by a sudden inhibition or letting go of the limb (relaxation) in response to a rapid stretch stimulus
Tone
• the resistance of muscle to passive elongation or stretch, a state of slight residual contracture in a normally innervated muscle
Type of sensory loss
•Tingling (paresthesia), numbness/diminished (hypesthesia), absent (anesthesia) (Nerve vs. nerve root involvement?)
Power wheelchair proportional drive controls: Conventional Joystick
- gimbal knob - on/off switch - speed control - battery gauge
Lead pipe rigidity
form of rigidity where there is uniform and constant resistance to ROM, often associated with lesions of basal ganglia
Types of wheelchair armrests: T-arm
- height adjustable by the patient, more support for the arms if you rest your arms on the armrests more - Heavier and more "disabled" looking
Brodmann's area 6
- higher stimulus required to cause a motor response ◦Supplementary motor area (SMA)-superiorly ◦Premotor area (PMA)—inferiorly
Deep sensation testing: Proprioception
"Awareness of movement" - Trial run or demo (pt and PT agree on terms) - Pt verbally describes the direction and range of mvmt "up, down, in, out, etc" while the extremity is in motion. - Alternately, pt can simultaneously duplicate the mvmt with the opposite extremity (difficult in hip) - Fingertip grip over bony prominences to reduce tactile stimulation -work distal to proximal - Small increments of range are used - Try not to be predictable so that the pt. cannot just guess - Make sure pt. vision is obscured
Health condition
"injury or disorder or trauma" (may include aging, congenital anomaly, etc.)
Wheelchair caster
"little wheels"
Common hip deviations during the gait cycle: limited flexion
(IC and LR 20deg flexion) -causes: may be intentionally to limit demand on weak hip extensors during LR, weak hip flexors, or single joint hip extensor; hamstring spasticity or contracture limiting terminal swing advancement before initial contact analysis: str of hip flex and ext; ROM of hip and for spasticity of hip extensors and hamstrings
Static postural control
(Stability, static equilibrium, or static balance): ability to maintain postural stability and orientation with COM over BOS (not in motion), BOS is fixed
Delirium
(acute confusional state) - often have impairments in immediate and STM along with confusion, agitation, disorientation, and usually illusions or hallucinations
Dynamic postural control
(controlled mobility, dynamic equilibrium, or dynamic balance): maintain postural stability and orientation with the COM over BOS while parts of body are in motion, BOS is fixed
Foot angle
(degree of toe out or toe in): the angle of foot placement with respect to the line of progression. Measured in degrees.
Types of wheelchair drive systems
***individual to drive needs of each patient - Rear-wheel - Front-wheel - Mid-wheel drive
Long Term Goals
- 4+ wks/discharge [functional] • State the long term outcomes of therapy (at least 3) • based on the therapy problem list • The basis for setting short term goals
5x sit to stand age norms
- 60-69 y/o 11.4 sec - 70-79 y/o 12.6 sec - 80-89 y/o 14.8 sec
Types of elevating leg rest on a wheelchair
*depends on pt. needs - Manual - Power -Center mount -Hanging mount
MDC and MCID for walking speed
*hip fractures are commonly seen
Re-Examination
*ongoing process - As the client progresses through a plan of care or across settings (eg. ICU to the medical floor or home care to outpatient), the baseline initial evaluation can be used as the basis for comparison of the patient's test values over time. Improvement, lack of progression and new or recurring problems can all be identified in this process. ► Evaluate interventions (within session) ► Modify or redirect intervention ►Treatment Note ► Evaluate progress (across sessions) ►Progress Note 10 visits/30 days ► Respond to new clinical findings identified during episode of care & over life span for some conditions ► Change requires Re-examination ► Establish new POC
Sit to stand
*tuck feet under, scoot to edge of chair, lean forward, put hands out if possible, and stand - one of the most physically demanding actions we perform regularly. Requires greater lower limb strength and ROM than walking and stair climbing. - Pre-extension phase: feet are moved backward to position the ankle joint posterior to the knee joint. Upper body (head, arms , trunk) rotates forward by flexing the hips and DF the ankles. - Considerations: - Standing up with one foot in front of the other increases the load thru posterior foot while decreasing anterior foot. - Standing up slowly reduces momentum and more lower limb force must be produced for a longer period of time. - A higher seat requires lower moments of force at the hips and knee joints. Lowering increases the amount of momentum. - Sitting down- performed by gravity and eccentric of extensor muscles that cross hips, knees and ankles in order to slow the descent.
Interlimb coordination
- (bimanual) integrated performance of two or more limbs working together - alternately flexing one elbow while extending the other; bilateral UE tasks as required during sliding transfers or dressing activities; or between limb movements of the LE's and/or UE's during walking.
Short Term Goals
- 1-4 weeks • The steps along the way to achieving long term goals (at least 3) • Based on the long-term goals • Serve as the basis for treatment planning
Skill
- Ability to consistently perform coordinated mvmt sequences for the purposes of investigation and interaction with the physical and social environment - UE reach and manipulation also Bipedal ambulation - Poorly coordinated mvmts; lack of precision, control, consistency, and economy of effort (ability to consistently perform coordination UE and LE mvmt to interact with environment; during locomotion COM is in motion and BOS is changing.) -timely, efficient, safe, coordinated
Topognosis
- Ability to identify the specific point of application of a touch stimulus and not simply the perception of touch
Static postural control (stability, static equilibrium, or static balance)
- Ability to maintain postural stability and orientation with the COM over the BOS with the body not in motion: - Holding in antigravity postures: prone-on-elbows, quadruped, sitting, kneeling, half-kneeling, plantigrade, or standing - Failure to maintain a stead body position; excessive postural sway; wide BOS; high guard position or handhold; loss of balance
Dynamic postural control (controlled mobility, dynamic equilibrium, or dynamic balance)
- Ability to maintain postural stability and orientation with the COM over the BOX while parts of the body are in motion - Weight shifting and reaching in any of the above postures - Failure to control posture during weight shifting or reaching tasks; loss of balance
Vibration perception testing
- Ability to perceive a rapidly oscillating or vibratory stimuli - 128 Hz tuning fork - Place on bony prominence Base is held in examiner's thumb and index finger - Touching tines will stop vibration - Test using randomly vibrating or non-vibrating - Vibration can be initiated for every stimulus, just stopped before placing on patient - Patient makes a response with every contact of the fork - Try to use occlusive earphones
Graphesthesia (traced figure identification) testing
- Ability to recognize letters, numbers, or designs traced on the skin - During the practice trial, agree on orientation of drawings - Between separate drawings the palm should be gently wiped with a soft cloth or hand to clearly indicate a change in figures to the patient
Compensatory approach for pt. with impaired sensation
- Achieve optimum functional capacity - Minimize activity limitations - Protect anesthetic limbs - Create appropriate environmental adaptations - Accommodate to the limitations imposed by the sensory deficit - Strategies include: -Testing bath water with contralateral limb (thermometer) -No barefoot walking -Skin checks -Adaptations
Types of foot plates on a wheelchair
- Adjustable (for child), rigid (for adults) - Tubular, full plate - Straps, heel loops
Wheelchair locks: Cam-locking: pull-to-lock
- Advantages of this brake is minimal if you have a SCI - Many people with strokes like this brake because it is easier to reach with uninvolved side over to the involved side (maybe using a brake extension), this lock is easier because you don't have to lean as far forward towards the weak side and possibly fall forward out of the wheelchair - for those manipulating lock with one hand - this is easier
Testing Two-Point Discrimination
- Aesthesiometer, circular two-point discriminator, or two reshaped paper clips (with ruler) - Alternate the application of 2 stimuli with random application of one stimulus. - The points are gradually narrowed until only a single point is perceived. - Patient should respond with "one" or "two"
Common coordination impairments of Basal Ganglia
- Akinesia - Athetosis - Bradykinesia - Chorea - Choreoathetosis - Dystonia - Hemiballismus - Hyperkinesis - Hypokinesis - Rigidity ◦Leadpipe ◦Cogwheel ◦Clasp Knife - Tremor (Resting)
Age related factors contributing to slowing of movements
- All stages of information processing are affected - Sensory losses: -Decline in receptor sensitivity, recognition, and sensory encoding (stimulus identification) - Response selection and programming affected -Reaction and mvmt times increase, coordination declines (fine-motor control) -Speed accuracy tradeoff - Coordination changes result from changes in motor unit size, noticeable in fine motor control. Accuracy is decreased as its speed is increased. To accommodate for this change, older adults typically move slower, especially when accuracy is required.
Common knee deviations during the gait cycle: wobble
- Alternating flexion/extension at knee joint during stance - Possible causes: consider proprioceptive impairments or alternating spasticity of knee flexors and extensors - Analysis: examine knee for proprioceptive impairments and spasticity
Sit to stand: Use of Armrests
- Assist in stability and force generation - frail elderly person relies on them
Tonic/Brainstem Reflexes
- Asymmetrical tonic neck (ATNR) - Symmetrical tonic neck (STNR) - Symmetrical tonic labyrinthine - Positive supporting - Associated reactions
Computerized Dynamic Posturography
- Based on the work by Nashner - Moving platform that introduces mechanical perturbations (sliding or tilting movements) - A moving visual surround screen is sway referenced and introduces visual conflict - Test condition 1 provides accurate somatosensory, visual and vestibular information and is the baseline reference - Each of the other six conditions systematically varies sensory inputs, increasing the level of sensory conflict and postural difficulty
Power wheelchair proportional drive controls: touchpad drive control
- Can be mounted almost anywhere - Can choose sensitivity
Pressure mapping for wheelchair prescription
- Can be used for comparison of peak pressures before and after custom seating is completed, patient and caregiver education regarding the importance of weight shifts and prevention of skin breakdown, medical documentation, and justification for funding sources. *important for choosing seat padding, ect.. - Areas at risk for pressure sores - there always has to be a way for the pt. to relieve these areas, take into consideration when prescribing
Treatment of Cerebellar Deficits
- Cerebellum is involved in motor learning. This may limit the effectiveness of rehabilitation programs in rehabilitation of cerebellar ataxia. - Rehabilitation programs are based on intensive static and dynamic balance training and coordination exercises ◦Takes longer to learn ◦6 months ◦>10 hours/week *General Approaches: ◦Functional task specific mvmt (with feedback) ◦Weight bearing activities ◦Aerobic Exercise (esp with hypermovement) ◦Resistance Training (esp with hypermovement) ◦Intensity and duration matters ◦Compensation - slow down their movements ◦Single limb movements ◦Visual cues ◦Widened stance ◦Minimize distractions - Static control exercises - Joint approximation and rhythmic stabilization (PNF) - Functional Activities - Aquatic therapy (provides graded resistance that slows down the patient's ataxic mvmts while the buoyancy aids in upright balance. Safe and effective balance major concern!) - Balance training - Weighted belts, cuffs, jackets and canes can help with choreic/athetosis movements - Frenkel's Exercises - Specific exercise techniques that can be used are joint approximation through proximal joints or through head and spine and rhythmic stabilization (PNF) would be a good choice
Drugs and memory
- Certain drugs can improve memory (CNS stimulants, cholinergic agents), other drugs can degrade memory (Benzodiazepines, anticholinergic drugs)
Sitting balance test
- Client performs with and without upper and lower extremity support or with and without trunk support (as skill level permits), with and without vision. Test for recovery from self-imposed perturbations (upper extremity or head movements) or external perturbations (gentle pushes by examiner). Observe resting preferred posture, tremor, sway, ability and effort required to maintain position, recovery from perturbations or other loss of balance. Inquire about vertigo, nausea, and subjective perception of stability.
Determination of level of accuracy (error correction) is referred to as:
- Closed- loop system: employs feedback, reference for correctness, computation of error, then correction to maintain desired state - Open-loop system: preprogrammed instructions: stereotypical mvmts, rapid, short-duration mvmts without time for feedback.
Movement and Cognition
- Cognitive processes are essential to motor control: attention, motivation and emotional aspects that underlie the establishment of intent or goals. - The study of motor control must include the study of cognitive processes as they relate to perception and action.
Aging and Coordination
- Decreased strength - Slowed reaction time ◦Speed-accuracy trade-off (speed will decrease to ensure greater accuracy) - Decreased ROM (biological aging of joint surfaces, degenerative changes in collagen fibers, dietary deficiencies, and sedentary lifestyle) - Postural changes (diminished strength and ROM, inactivity, and prolonged sitting (forward head, rounded shoulders, lordotic curve changes, hip/knee flexion) Increased postural sway: oscillating movements of body over feet during relaxed standing) -reduction in postural limits of stability -reduction of functional reach magnitude (may be lack of awareness of their limitations so the planned movements resulted in a loss of balance) - Impaired balance (postural control/increased postural sway) - An aging neuromuscular system maintains its physiological adaptive response to training stimuli. PT promotes a more successful approach to aging.
Kinematic gait analysis
- Describe mvmt patterns without regard for the forces involved in producing the movement -Description of movement of the body as a whole and/or body segments in relation to each other during gait 1. Qualitative -Observational Gait Analysis (OGA) 2. Quantitative (gait speed, etc.)
Superficial sensation testing: Touch awareness
- Determines perception of tactile touch input - Piece of cotton (ball or swab), or tissue - The area to be tested is lightly touched or stroked - Patient indicates "yes" or "now i can feel it" - Make sure vision is obscured
Reasons to perform a sensory examination
- Diagnostic purposes -how extensive damage is -level of injury with SCI - Track progress/regression - Safety -can they perceive pain, hot/cold? Lack of sensation? - Compensatory strategies -absent, under, or over perceiving
Obtunded
- Difficult to arouse from a somnolent state, confused when awake - Repeated stimulation required, tx unproductive - dulled or blunted sensitivity
Overview of Motor System
- Divided into: 1. Peripheral 2. Central *Highest level: association areas of cortex and basal ganglia ◦ Strategy: defines best movement strategy to achieve the desired goal *Middle level: motor cortex and cerebellum ◦Tactics: sequences motor contractions for smooth and accurate completion of goal *Lowest level: brainstem and spinal cord ◦ Execution: activation of motor neuron/interneuron pools generating goal-directed mvmt and adjustments of posture
Examination of ambulation skills:
- Does pt need assist? - Change in pt's status - Screen for need of PT - Identify risk of falling
Vestibulo-ocular reflex (VOR)
- Dolls eyes - A reflex eye movement that stabilizes images on the retina during head movement by producing an eye movement in the direction opposite to head movement, thus preserving the image on the center of the visual field. For example, when the head moves to the right, the eyes move to the left, and vice versa. Since slight head movement is present all the time, this is very important for stabilizing vision: patients whose ________ is impaired find it difficult to read using print, because they cannot stabilize the eyes during small head tremors. - It does not depend on visual input and works even in total darkness or when the eyes are closed. However, in the presence of light, the fixation reflex is also added to the movement
Lethargic
- Drowsy-may fall asleep, difficulty in focusing/attention - general slowing of motor processes (speech and mvmt), keep instructions simple & direct, speak in a loud voice calling the pt. name
Pattern or distribution of symptoms
- During review of systems, ask pt to describe the _____________________________________ (tingling, numbness, diminished, absent sensation) - This provides the therapist with preliminary information to help guide the examination and to assist in identifying the dermatome and nerve involved
Front-rigging on a wheelchair
- Footplate attached to a footrest or elevating leg rest - There are also center-mount (mostly in power wheelchairs) - Swing-out or swing-in - Most swing out - and when doing transfers - if you have pt with fragile skin remove it. - Allows closer to couch/bed, etc. Removable footrests typically pivot to the side. Most all rigid frame chairs have non removable front rigging: unitized construction design and can not be adjusted except for the angle adjustability. - Can be valuable in transfers as another position to place hand. They can be ordered 60 degrees to 110 degrees hanging angle. - 110 can shorten the overall dimensions of a wheelchair but then that also increases the chance of sores on back of leg because set depth is eaten up.
Wheelchair components: anti-tippers
- For people that are very active and need to ride wheelies to descend steep hills, for jumping curbs, etc., these will get in the way and prevent independence in some of those areas - Take into consideration when prescribing wheelchair - what will their ability level be in the future? Will they always need this feature? Will this feature hinder them?
Documentation: Plan
- For the patient's treatment - One or more interventions to achieve each of the short term goals • Included: •Frequency/day or week •Tx the pt will receive •If D/C note: where the patient is going and the number of times the patient was seen in therapy •Location (gym, bedside, outside) •Tx progression •Plans for further assessment •Plans of D/C •Pt/family education •Equipment needs •Referral to other services ► Includes anticipated goals and expected outcomes ► Outlines the planned interventions to be used ► Describes frequency, length of service, specific interventions, tx progression, educational strategies ► Documents referrals to other professionals
Major types of wheelchair armrests
- Full or desk length - Removable or fixed - Tubular - Platform - T-arm - Trough's/tray - Elevating
Cranial Nerves II, III (Optic and oculomotor)
- Function: 1. pupillary reflexes - Test 1. Test pupillary reactions (constriction) by shining light in eye ; if abnormal, test near reaction AbN. absence of pupillary constriction - Test 2. Examine pupillary size-shape AbN . Anisocoria (unequal pupils), Horner's syndrome, CN III paralysis
Facial Nerve (CN VII): Motor Function
- Function: Facial expression - Test: Test motor function facial mm, raise eyebrows, frown. Show teeth, smile. Close eyes tightly, puff out both cheeks. - AbN: paralysis: inability to close eye, drooping corner of mouth, difficulty with speech articulation. -Unilateral LMN: Bell's palsy -bilateral LMN: Guillain-Barre -Unilateral UMN: stroke • innervation to facial mm • UMN versus LMN Facial Weakness • Efferent output to Corneal Blink Reflex • Other Functions • Parasympathetic input to lacrimal, sublingual, and submandibular glands • Motor input to stapedius muscle
Glossopharyngeal Nerve (CN IX)
- Function: Gag Reflex - Test: stimulate back of throat lightly on each side - ABN: absent reflex: lesion of CN IX; possibly CN X
Abducens (CN VI)
- Function: Lateral rectus: turns eye out - Test: observe position of eye, Test eye mvmts - AbN: Esotropia (eye pulled inward), Eye cannot look out.
Oculomotor (CN III)
- Function: Medial, superior, and inferior rectus: inferior oblique; turns eye up, down, in - Test: Observe position of eye. Test eye movements - AbN: strabismus: eye pulled outward by CN VI, Eye cannot look upward, downward, inward movements.
Vagus Nerve (CN X)
- Function: Palatal, pharynx control - Test: Have pt say "ah"; observe motion of soft palate (elevates) and position of uvula (remains midline) - AbN: Paralysis: palate fails to elevate (lesion); asymmetrical elevation with unilateral paralysis - If one side is paretic, the uvula is lifted away from the paretic side
Trochlear (CN IV)
- Function: Superior oblique: turns eye down when adducted - Test: test eye mvmts - AbN: eye cannot look down when eye is adducted
Hypoglossal Nerve (CN XII)
- Function: Tongue movements - Test: Listen to patient's articulation Examine resting position of tongue Examine tongue movement: ask pt to protrude tongue, move side-to-side - AbN: Dysarthria (seen with lesions of CN X or CN XII, also V, VII) Atrophy or fasciculations of tongue (LMN, ALS) impaired mvmts, deviations to weak side UMN lesion: tongue deviates away from side of cortical lesion. - evaluated by asking the patient to extend the tongue and inspecting it for atrophy, fasciculations, and weakness (deviation is toward the side of a lesion
Sensory functions
- Guides selection of motor responses for effective interaction with the environment - Adapt mvmts and shape motor programs through feedback for corrective action - Protecting the organism from injury (pain)
Rigidity
- Hypertonic, constant resistance throughout ROM, velocity-independent of movement. - Also seen in lesions of basal ganglia (extrapyramidal) and Parkinson's disease - Result of excessive supraspinal drive (inc UMN tone) - increase in mm tone causing greater resistance to passive mvmt; greater in flexor mm - leadpipe: uniform, constant resistance as limb is moved - cogwheel: series of brief relaxations or "catches" as limb is passively moved - clasp-knife: A manifestation of corticospinal spasticity in which there is increased tone in either flexion or extension with sudden relaxation, as the muscle continues to be stretched
Precautions for functional training
- Orthopedic injuries - WB or ROM precautions - Head of bed elevation restrictions - Orthostatic hypotension - Practice functional skills with your patients! - Static sitting -Hands on the EOB, give cues to assist pt to obtain midline - Dynamic sitting -Reaching out of base of support - Increase the cognitive awareness of inattention or imbalance
Common hip deviations during the gait cycle: excess flexion
- IC: -cause: single jt hip extensor weakness (glut max, adductor magnus) with compensation by hamstring; severe hip and/or knee flexion contractures; hypertonicity of hip or knee flexors analysis: examine single jt hip ext and hamstring str; hip and knee flexion ROM, tone, and spasticity - MSt through PSw: -cause: hip flexion or knee flexion contracture or spasticity; weak PF failing to control excess tibial advancement; painful or effused hip. analysis: examine tone and spasticity of hip/knee flexors; ROM hip /knee; str PF and hip for joint point - Swing: -cause: compensatory to assist with limb clearance if limb is functionally too long; flexion synergy during swing resulting in too much flexion analysis: examine for compensation, determine if ankle and knee of reference limb are achieving correct joint positions. Examine contralateral limb to determine if deviations are occurring on opposite side-could contribute to clearance problems on reference side
Common pelvis and trunk deviations during the gait cycle: backward trunk lean
- In stance or swing - Cause: purposeful to reduce demands on weak stance limb glut max or to assist with limb advancement when hip flexion capability is limited - Analysis: examine hip extensor and flexor strength
Prioritized Problem List
- Includes the major areas that were not within normal limits when the subjective interview and objective testing were performed, written as a list format (bullet or numbered) - Each one is covered by a long-term goal!
Pain perception: Sharp/dull discrimination testing
- Indicates function of protective sensation *do it on uninvolved side first (or cheek) - The pin should be sharp enough to deflect the skin, but not puncture it - Ask pt to verbally indicate "sharp" or "dull" - All areas of the body may be tested
Basal Ganglia
- Influences on mvmt: • Initiation and regulation of gross intentional mvmts • Planning and execution of complex motor responses • Facilitation of desired motor responses (while selectively inhibiting others) • And the ability to accomplish automatic movements and postural adjustments • Maintaining normal background muscle tone
Power wheelchair types
- Joy stick - Head support - Attendant control - Power elevating legs - Tilt and recline
Common knee deviations during the gait cycle: limited knee flexion
- Less than 20 degrees - Loading Response: -possible causes: intentional to decrease demands on weak quads; 2° PF or quad tone, spasticity, or contracture; or proprioceptive impairment at knee. Analysis: examine strength, tone, spasticity of PF and quad; PF and knee extension Rom; knee proprioception - Pre-swing and initial swing: -possible causes: 2° PF tone, spasticity or contracture that limits forward tibial progression in TSt; quad tone, spasticity; proprioceptive impairment at knee; knee pain or effusion; calf weakness or hip flexion contracture that limits ability to achieve the trialing limb posture in TSt. ISw, weakness of knee flexors also may contribute - Analysis: examine tone and spasticity of PF, vastii and rectus femoris; ROM and knee proprioception. Pain and effusion. Examine PF str and hip flexion contracture. Evaluate if these inhibit optimum limb posture
Cerebellar/ Coordination Medical Management
- Limited - NO CURE - No substantiated medications - Rehabilitation ◦Some natural recovery ◦Improvement through rehab *IPSELATERAL to the side of LESION
Points to consider for individuals with cognitive (attention/memory) deficits
- Maintain age-appropriate communication style - Keep instructions simple, brief (1 or 2 level commands) - Use a closed environment - Use demonstration & positive feedback - Use of any memory-enhancing strategy
Reclining wheelchair
- Manual or power - Can cost upwards of $20,000
Tilt in space wheelchair
- Manual or power - Keeps pt. in seated position, but tilts them back - Can help with BP regulation - Can help with pressure relief
Essential functional skills
- Mobility - Static Postural Control (stability, static equilibrium, static balance) - Dynamic postural control (controlled mobility, dynamic equilibrium, dynamic balance) - Skill *the heart of neuro-rehab - evolving process, that proceeds from infancy and childhood. Often referred to as developmental motor skills - Examples include rolling, supine-to-sit, sit-to-stand, maintaining stability or moving in progressively more challenging antigravity postures, UE manipulation, locomotion
Spinal Accessory Nerve (CN XI)
- Motor Function: trapezius muscle, sternocleidomastoid - Test: examine bulk, strength, shrug both shoulders upward against resistance (trap), turn head to each side against resistance (SCM) - ABN: LMN: atrophy, fasciculations, ipsilateral weakness inability to shrug ipsilateral shoulder; shoulder drops Inability to turn head to opposite side UMN: weakness of ipsilateral sternocleidomastoid and contralateral trapezius
Power wheelchair non-proportional drive controls: Scanner Drive Control
- Mounted display with lights to control w/c. When not moving, the lights rotate in a predictable fashion and driver selects command. ie, laser
The musts of a sensory exam
- Must have a structure ready to meet the needs of ANY patient with a neurologic disease/condition - Must know "Normal" - Must know what to expect for pt. responses/results given: The diagnosis/condition, severity, stability, stage of disease/recovery, age, setting, etc.
Trunk control
- Normal movements of the trunk: flexion, extension, lateral flexion, rotation, shortening, elongating - Observe during movement or static posture if the patient is able to fulfill ROM requirements for normal" trunk motions to occur.
PT examination of muscle tone
- Observation: KEY 1st step -note the posture, movement, motor control of your pt. - Palpation of muscle belly - Take joint through passive movement and assess: -Muscle tone -Spasticity - With all: compare sides, distal vs prox
Dual Tasking (Exam and Intervention)
- Performing a secondary motor or cognitive task while seated, standing, or walking ◦ Parkinson's disease often demonstrate significant impairment in this -Count backwards from 100 by 7's, -pour water into a glass -Add cards while walking -Bounce/kick a ball -Identify a fruit/vegetable/name beginning with each letter of alphabet
Single Limb Support (SLS)
- Period when the body progresses over a single, stable limb. Weight is transferred onto the metatarsal heads and the heel comes off the ground. 3. Mid Stance 4. Terminal Stance
Weight Acceptance (WA)
- Period when weight is rapidly loaded onto outstretched limb. Impact of the floor-reaction force is absorbed, body continues in a forward path while stability is maintained. Both feet are in contact with the ground. 1. Initial Contact 2. Loading Response
Glossopharyngeal and Vagus Nerves (IX, X)
- Phonation, swallowing - Afferent (IX) and Efferent (X) components for the Gag Reflex - Vagus: Nerve also does all parasympathetics from the neck down until the mid-transverse colon - Function: Phonation, Swallowing - Test: Listen to voice quality, examine for difficulty in swallowing glass of water. - ABN: Dysphonia: hoarseness denotes vocal cord weakness; nasal quality denotes palatal weakness; dysphagia
Wheelchair locks: Cam-locking: push-to-lock
- Placed on many lightweight wheelchairs, they are good for people with weak hands: - good for slowing down the wheels when descending a ramp, however, this is discouraged - They are also more out of the way when performing a transfer
Matrix of wheel
- Pneumatic -Foam filled, solid rubber, kix
Common knee deviations during the gait cycle: hyperextension
- Possible causes: structural abnormality (presence of flaccid/weak quad compensated by excess PF and or posterior pull on thigh by glut max; quadriceps spasticity accommodation to fixed PF deformity, impaired proprioception can contribute to hyperextension if knee is exposed to deforming forces for extended duration - Analysis: examine strength of vastii; tone, spasticity of PF and quad; ROM and knee proprioception
Common pelvis and trunk deviations during the gait cycle: forward trunk lean
- Primarily in stance - Cause: compensate for quad weakness; forward lean reduces knee extensor moment and thus demand on vastii. Accommodate hip or knee flexion contractures - Analysis: examine quad str and hip/knee for contractures
Brodmann's area 4
- Primary motor cortex (PMC) - Contains the largest concentration of corticospinal neurons ◦Highly excitable, low intensity stimulus required to cause a motor response
Gait ataxia
- Probably the greatest complaint and the most obvious sign of cerebellar damage - This abnormal pattern of walking is often described as a "staggared" gait because clients often stagger and lose balance. - Variability -clients with cerebellar damage walk without the consistency in timing, length, and direction of steps typical seen in healthy adults. Walking is slowed, with steps that are short, irregular in timing, and unequal in length. The legs sometimes lift overly high during the swing phase by excessive flexion at the hip and knee and then lower abruptly and with uncontrolled force. The trajectory of walking often veers erratically and patients have difficulty with stops or turns, especially if performed quickly.
Documentation: Assessment
- Professional judgments and/or PROBLEM LIST about subjective and/or objective findings. - Short-Term Goals - Long-term goals - Rehab potential (as part of POC) - Prioritized problem list with impairments linked to functional limitations (PT problems-what you can address to help resolve) ► The physical therapy diagnosis is determined
Cortical sensory processes include
- Proprioception/kinesthesia - Pallesthesia - Stereognosis - Topognosis
Cranial nerve testing
- Provides information on: -location of dysfunction within the brainstem -identification of CN requiring detailed examination - Testing patients with damage to brain, brainstem, or upper cervical spine *differentiates between upper and lower motor neuron lesions
Patient preparation for sensory examination
- Pt rested and comfortable - Wash hands! - "Trial run" or demonstration so theres no fear - Method of occluding the vision - Applied random, unpredictable with variation in timing - Work distal to proximal -Deficits tend to be more severe distally - Document: modality, quantity, degree, localization
Types of gait analyses
- Qualitative (observational) - Quantitative (spatial and temporal)
Documenting a muscle tone exam
- Quantitative -Ashworth Scale -Tardieu - Descriptive -Minimal, moderate, severe -Not standard so best to use descriptors -(tone increase such that obtaining full ROM is difficult) - Relative -R vs L (comparing to their normal); distal vs prox, UE vs LE - Goals must relate to function
Sit to stand: Momentum Transfer strategy
- REQUIRES: -Adequate strength and coordination -Eccentric contraction of trunk and hip ms -Concentric contraction of hip and knee ms to lift body *appropriate for someone with hemiparesis, weak, need to rely on this - used initially usually
Deep sensation receptor function: Proprioceptors
- Receive stimuli from muscles, tendons, ligaments, joints, and fascia - Position sense/awareness of joints at rest - Kinesthesia - movement awareness - Vibration *MM spindle, GTO, free nn endings, pacinian corpuscles
Exteroceptors
- Receive stimuli from the external environment via the skin and subcutaneous tissue - They sense: -Pain -Temperature -Light touch -Pressure
Forward reasoning process
- Tends to be utilized by experienced or expert clinicians - Able to recognize cues and patterns from similar previous cases. Decisions based on intuition. Hypothesis testing not verbalized. Pattern recognition and experiential clinical knowledge.
Cerebellar Treatment: Aerobic exercise and resistance training
- Recommended for a majority of clients with cerebellar dysfunction, particularly if it is expected the client will not regain premorbid status. If full recovery is not attained, nearly all types of movements will be generally more effortful, requiring increased energy expenditure and demanding greater concentration. It is well known that repetitive fatiguing activity worsens postural control and therefore may contribute to trips, falls, or other injuries. Because imbalance is such a common outcome for clients with cerebellar dysfunction, incorporating both aerobic exercise to improve cardiovascular endurance and submaximal resistive exercise to improve muscle fatigue resistance appears appropriate. Aerobic exercise activities might include walking, dance, recumbent or stationary cycling, rowing, arm ergometry, swimming and aquatic exercise, as well as many other possibilities.
Common pelvis and trunk deviations during the gait cycle: ipsilateral trunk lean
- Reference limb stance - Cause: occurs during reference limb stance. Compensation for ipsilateral hip abductor weakness, hip joint pain, ITB tightness or scoliosis - Analysis: examine ipsilateral glut med str; hip pain and ipsilateral ITB tightness and for trunk ROM
Common pelvis and trunk deviations during the gait cycle: contralateral trunk lean
- Reference limb swing - Cause: assist with pelvic elevation to ensure foot clearance (functionally too long). Compensate for contralateral hip abductor weakness, hip joint pain, iliotibial band tightness, scoliosis - Analysis: contralateral glut med str, hip pain and ITB tightness and trunk ROM. Leg length discrepancy
Types of push rims on wheelchairs
- Regular (circular, slippery, standard) - Natural fit (designed to fit in the hand easier, a bit bigger, easier to have a grip - best for person who will be in w/c for most of locomotion needs) - Non-slip coating (good for those with problems gripping) - Projections (particularly useful for people with SCI, dont have to reach as far down) - Push-assist (usually electric)
Environment
- Regulatory features: -Size, shape and weight of the cup -Height of the transfer surface -Surface on which you are walking - Nonregulatory features: -Background noise (especially in those with cognitive impairments) -Presence of distractions -play a huge hand in neuro patients. You may have to do a treatment in an isolated room, with blinds, quiet environment, no family present or mother may be needed to comfort - Features of the _____________________ can enable performance or alternatively, they may disable or hinder performance. Walking in a well-lit room makes it easier to walk. Standing in a dark movie theatre, you may not be able to move your legs. Sizes of small obstacles and other surface properties, etc.
Stupor
- Responds only to strong noxious stimuli, returns to the unconscious state when stim is stopped - semiconsciousness: lacks responsiveness, only aroused with intense stimuli (painful stimuli: sharp pressure, pinch, crush nail bed)
Street crossing gait speeds
- Rural 45 m/min (0.7 m/sec) - Urban 48 m/min (0.8 m/sec) - Busy city street: 70 m/min (1.17 m/sec)
Squeeze/bucket
- Seat to backrest angle on wheelchair - 90 degrees is standard in a hospital issued w/c, most active users chose at least a little bit of "squeeze" or "bucket". - The advantages of a lot of squeeze: keeps the hips into the chair and helps people feel more stable. - The disadvantage is: harder to transfer "uphill" if transfers are a challenge for the patient
Sensory integration model
- Specific treatment techniques can enhance sensory integration (CNS processing) with a resultant change in motor performance - Data obtained from exam of sensory function informs development of POC to enhance opportunities for controlled sensory intake within a framework of meaningful functional skills - The goal: improve ability of CNS to process and integrate information and promote motor learning
Spinal pathways
- Spinothalamic (anterolateral) - Dorsal Column
Common pelvis and trunk deviations during the gait cycle: contralateral pelvic drop
- Stance - Cause: ipsilateral hip abd weakness, hip add spasticity, or hip add contracture - analysis: examine strength, flexibilty, and tone of ipsilateral hip abductors and adductors
Components of limits of stability
- Steadiness refers to the ability to maintain a given posture with minimum movement (sway) - Postural sway: normal amounts of small range postural shifts - Sway envelope: the path of the body's mvmt during standing In the erect standing posture the body undergoes a constant swaying motion called postural sway or sway envelope •Sway envelope for a normal individual ,standing with 4" b/w the feet - 12° in sagittal plane and 16° in frontal plane.
Testing recognition of texture
- Suitable textures cut in 4" x 4" pieces are given to patient to manipulate in hand. (Cotton, wool, silk) - They may be identified by name (silk, cotton) or by texture (rough, smooth)
Levels of assistance
- Supervision - CGA - Min - Mod - Max - Dependent
Common pelvis and trunk deviations during the gait cycle: pelvic hike
- Swing - Cause: action of quadratus lumborum to assist with limb clearance when hip flexion, knee flexion and/or ankle DF are inadequate for limb clearance - Analysis: examine strength and ROM at knee, hip and ankle; examine mm tone at knee and ankle.
Common pelvis and trunk deviations during the gait cycle: ipsilateral pelvic drop
- Swing - Cause: contralateral hip abductor weakness, hip adductor spasticity or hip adduction contracture - Analysis: examine strength, flexibility, and tone of contralateral hip abductors and adductors
Testing Stereognosis
- Tactile object recognition - Allow the patient to handle several sample test items during the explanation. - Culturally familiar object of different sizes and shapes (key, coin, comb, safety pin, pencils, etc) - "Name the object verbally" Or "identify from a group of images"
Task-oriented training strategies
- Tasks important for daily function/ independence - Consider past hx to make stimulating activities - Involve patient in goal setting - Tasks with potential for success - Target active movements - Repetition and extensive practice - Guide patient to carry out initial mvmt - Provide augmented verbal feedback - Start in non-distracting environment - Progress to real world environment *Always consider what does the patient need to go home? What are the tasks he/she has difficulty performing?
Swing Limb Advancement (SLA)
- The Time when the limb is unloaded and the foot comes off the ground. The limb is moved from behind the body to in front, reaching out to take the next step. - To meet the high demands of advancing the limb, preparatory posturing begins in stance 5. Pre-Swing 6. Initial Swing 7. Mid Swing 8. Terminal Swing
Wheelchair locks: Low-mount scissor lock
- The brake is more out of the way and cause less damage to thumb when propelling harder and faster - Disadvantage: you usually have to have more finger strength (and arm strength) to lean forward and set the brake, then return to a sitting position - Not appropriate for most people lower C6 and below
Task
- The nature of the _________ being performed determines the type of movement needed - You must understand how they regulate neural mechanisms controlling movement - Recovery of function: develop movement patterns that meet the demands of functional ones - What ones should be taught, what order, what time?
PT intervention
- The purposeful interaction of the PT with the patient/client and, when appropriate, other individuals involved in the care of the patient/client, using various physical therapy procedures and techniques to produce changes in the condition. ►Coordination, Communication and Documentation ►Patient/Client-related Instruction ►Procedural Interventions ►Delegation
Athlete single leg stability testing
- The test protocol allows clinicians to test athletes against data derived from studies using the Biodex Balance System. The low stability level of four will challenge athletes and provide the data necessary to assess the athlete's single leg postural stability.
Crutch fitting
- The top of each crutch should be about two finger widths from the underarm and his anatomical snuffbox should be even with the hand grips when his arms hang at his side - Measure from the fold under the person's arm to a spot on the floor that is approximately 2 inches ahead and 6 inches to the side of his foot if the person is standing up. If the person is lying down, measure from the front of the underarm fold to the heel and subtract 2 inches
The limits of stability (LOS) test
- This test challenges patients to move and control their center of gravity within their base of support. This test is a good indicator of dynamic control within a normalized sway envelope. Poor control, inconsistencies or increased times suggests further assessment for lower extremity strength, proprioception, vestibular or visual deficiencies may be indicated
Communication board
- To ensure the validity of the PT exam, it is necessary to identify an appropriate means of communicating with the patient - For teaching, it is imperative also - other options include some now for iPad, also electronic, etc. OTHER FACTORS : sensory integration,sensation, joint mobility
Kinematic quantitative gait analysis
- To obtain information on spatial and temporal gait variables as well as motion patterns. →quantifiable and therefore provide PT with baseline data that can be used to plan treatment programs and evaluate progress towards goals →The fact that the data are quantifiable is important because third-party payers are demanding that therapists use measurable parameters when examining pt function, establishing treatment strategies, and documenting the outcomes of a plan of care. - However, data derived from qualitative observations may be necessary to determine degrees of motor impairment, and to check the validity of the quantitative variables measured.
Testing Kinesthesia
- Trial run or demo first - Make sure pt. eyes are closed - Patient can simultaneously duplicate the position with the contralateral extremity (difficult in hip) - PT fingertip grip over bony prominences to reduce tactile stimulation - Small increments of range are used - pt. describes the position (initial , mid, end range)
Superficial sensation testing: Temperature awareness
- Two test tubes with stoppers One with warm water (115˚F - 120F), other with cold water (41˚F - 50˚F) - The side of the tube is typically placed in contact with the skin, not the distal end - Response is "hot" or "cold"
cogwheel rigidity
- Type of rigidity in which the increased tone is released by degrees during passive range of motion - superimposed ratchet-like jerkiness
Higher Level Goals
- Upright posture - Head and trunk control - Midline orientation - OOB for a determined amount of time - Orientation - Establish baseline for sensory stimulus and response - Memory aides: signs in room, for orientation and precautions
FGA - Functional Gait Assessment
- Used to assess postural stability during walking and assesses and individual's ability to preform multiple motor tasks while walking. Modification of the DGI. - Highest score = 30 - Can preform with or without a device. - Normative data for specific populations and general age norms
Scooters
- Usually have a captain's chair, good for those with decreased endurance. If a person receives one, has a stoke or other disability, then wouldn't qualify for another seated device.
Tardieu Spasticity Scale
- Velocity of stretch: -SLOW - as slow as possible -FAST - as fast as possible (faster than the rate of natural drop of the limb under gravity) - Quality of muscle Reaction: 0 = no resistance through the course of passive movement 1 = slight resistance throughout the course of the passive movement with no clear catch at a precise angle 2 = clear catch at a precise angle, interrupting the passive movement, followed by release 3 = fatigable clonus (<10 s) while maintaining pressure) occurring at a precise angle 4 = unfatigable clonus (<10 s) while maintaining pressure) occurring at a precise angle
Postural Alignment and Sway Exam
- Visual inspection - Posturography (manipulate sensory systems and can track person's weight shifting) - SOT (sensory organization test)/CTSIB - Biodex
When does the gait cycle begin?
- When the heel of the reference extremity contacts the surface and ends when the heel of the same extremity contacts the surface again (or when some other portion of the reference extremity comes in contact with the ground)
Weighted Belts and Equipment
- can help with hypermovement disorder patterns - once the weight comes off the pt., however, the movement goes back to the way it was - temporary fix
Neuroplasticity
- a continuum from short-term changes in the efficiency or strength of synaptic connections to long-term structural changes in the organization and numbers of connections among neurons. • The capacity of the brain to adapt to injury through mechanisms of repair and change • Short term changes: efficiency or strength of synaptic connections • Long-term changes: structural changes in the organization and numbers of connections among neurons • Maximize rehab protocols based on ____________________ principles
Stretch reflex (myotatic reflex)
- a muscle contraction in response to stretching within the muscle - It is a monosynaptic reflex
Huntington's disease, chorea, (HD)
- a neurodegenerative genetic disorder that affects muscle coordination and leads to cognitive decline and dementia. It typically becomes noticeable in middle age - most common genetic cause of abnormal involuntary writhing movements called chorea. - It is much more common in people of Western European descent than in those of Asian or African ancestry. The disease is caused by an autosomal dominant mutation on either of an individual's two copies of the gene, which means any child of an affected parent has a 50% risk of inheriting the disease. In the rare situations where both parents have an affected copy, the risk increases to 75%, and when either parent has two affected copies, the risk is 100% (all children will be affected). - Physical symptoms can begin at any age from infancy to old age, but usually begin between 35 and 44 years of age.
Grading muscle tone
- a qualitative determination of the degree of tone should be made: 0 No response (flaccidity) 1+ Decreased response (hypotonia) 2+ Normal Response 3+ Exaggerated response (mild/mod hypertonia) 4+ Sustained response (severe hypertonia) ●(Hypertonic limbs feel stiff and resistant to mvmt) ●(Flaccid limbs feel heavy and unresponsive)
Opisthotonus
- a state of a severe hyperextension and spasticity in which an individual's head, neck and spinal column enter into a complete "bridging" or "arching" position - This abnormal posturing is an extrapyramidal effect and is caused by spasm of the axial muscles along the spinal column. Seen in tetanus
Decerebrate rigidity
- abnormal extensor response: sustained contraction and posturing of the trunk and limbs in a position of full extension *associated with more severe brain injury
Decorticate rigidity
- abnormal flexor response: sustained contraction and posturing of the upper limbs in flexion and the lower limbs in extension - CST lesion at diencephalon (above sup colliculus); decerebrate: CST lesion in brainstem (between superior colliculus and vestibular nucleus)
Factors within the individual that constrain movement:
- action - perception - cognition
20" wheelchair wheel
- appropriate really small person who is post CVA and has to be a foot propelling either with one or both legs - Transferring over them is easier, however, it also puts the entire chair very low so reaching onto counters is difficult
Power wheelchair non-proportional drive controls: Head control
- by adding proximity switches to the headrest which the user activates to go left, right and forward - As with the proportional system, the user must activate another switch to change directions from forward to reverse. The user does not have to hold constant pressure on the switches to drive the chair. The user can't actually use the headrest, as a headrest, unless power to the chair is turned off. The disadvantage of a non-proportional drive headrest systems is that there is no way for the user to adjust their speed while driving.
Compensatory strategies
- can be defined as atypical approaches to meeting the requirements of the task using alternative mechanisms not typically used, for example, standing with the weight shifted to the non paretic leg following a stroke. - can also reflect modifications to the environment that simplify the demands of the task itself. For example, grab bars may be installed to assist a patient in transferring onto and off of the toilet.
Ultra light-weight folding wheelchair
- can be expensive and high performance many people that travel by air a lot like these - More folding parts means more weight, more maintenance, less responsiveness.
Dynamic Neuromuscular Stabilization (DNS)
- can be used to assess and restore an ideal muscle synergy to stabilize the core. - based on comparing the patient's stabilization pattern with the stabilization patterns typical for physiological development. - A healthy infant automatically utilizes ideal muscular synergy to stabilize their spine, pelvis and chest in various positions. - this is based on the developmental positions and describes a set of functional tests to assess the quality of patient's stabilization and to recognize a key link in dysfunction. - The treatment is based on developmental positions - The goal is to achieve optimal muscle coordination by placing the patient into various developmental positions while bringing the supporting joints and segments into a functionally concentrated position. - The training also addresses simultaneous stabilizing and respiratory functions. - The ultimate goal is to teach the patient the integration of an optimal pattern of breathing and stabilization within the activities of daily living and sport performance.
A comparison of the stages of recovery from stroke table
- can get stuck in a stage and stay there, but will follow this order if they dont get stuck at a stage
GAITMAT II
- capable of real-time quantitative analysis of gait. It consists of an instrumented walkway and an IBM compatible computer running the GaitmatTM II software. The walkway is 12 feet long, 40 inches wide, and 1 inch high. The surface of the walkway contains 9728 switches arranged in 38 rows, with each row containing 256 switches. The switches are normally open. When a subject traverses the mat, the switches transiently close and then reopen as the subjects feet contact and break contact with the mat. The states of all switches are constantly monitored by the computer. When a switch closes and then reopens, the computer records the closing and opening times. In this manner, both the temporal and spatial characteristics (stride length, double support time, step length, step time, average velocity, etc) of the patient's gait are obtained. - Insoles containing four-pressure sensitive switches placed under the heel and at the head of the first and fifth metatarsals and the great toe. Stride length, velocity, cadence, cycle time, single and double limb support time, swing time, stance time.
Power wheelchair proportional drive controls: Compact Joystick
- chin: the gimbal is mounted on a swingaway mount
Power wheelchair proportional drive controls: finger control
- control box can be mounted just about anywhere the user can comfortably reach
MoCA - The Montreal Cognitive Assessment
- designed as a rapid screening instrument for mild cognitive dysfunction. It assesses different cognitive domains: attention and concentration, executive functions, memory, language, visuoconstructional skills, conceptual thinking, calculations, and orientation. - Time to administer is approximately 10 minutes. - The total possible score is 30 points; a score of 26 or above is considered normal
Activity limitation
- difficulty an individual may have in executing tasks or actions - Limitations of cognitive, learning, communication, mobility - Example Stroke: bed mobility, gait, transfers, stairs, BADL's IADLS (cleaning, finances, preparing meals, shopping, telephoning
Sign
- directly observable/measurable - amount of effusion, blood pressure, Difficulty with word finding, ROM
Walking velocity
- distance/time - affected by age, level of maturation, height, sex, type of footwear, weight
Movement strategies for Balance: Ankle strategy
- disturbance of COM small and within LOS - distal to proximal sequence - forward sway: gastrocnemius is activated first, followed by hamstring, then paraspinal muscles - backwards sway: anterior tibialis, quadriceps then abdominals
Power wheelchair non-proportional drive controls: Proximity switch
- do not require pressure to be activated - purchased loose and mounted virtually anywhere
Power assist wheelchair
- eMotion - Quickie XTender
Postural tremor
- exaggerated oscillatory mvmt of the body in standing posture or of a limb held against gravity - involuntary rhythmic, oscillatory mvmt observed at rest typically disappear or decrease with purposeful mvmt, increases with emotional stress.
Coma
- eyes do not open, does not follow commands, does not mouth or utter meaningful words, no intentional mvmt, does not sustain visual pursuit, cannot be aroused by any type of stimulation - no sleep/wake cycles. Reflex may be absent depending on location of the lesion within the CNS
Abnormal observations linked with tasks: Disturbance of posture
- fixation or position holding (UE; LE) - displace balance unexpectedly in sit or stand - standing, alter base of support (tandem stance or SLS)
Location of shocks on manual wheelchairs
- for front caster - Rear shock absorption *depends on how heavily wheelchair will be used, what kind of terrain, and skills of pt.
Sydenham's chorea or chorea minor (historically referred to as Saint Vitus Dance)
- is a disease characterized by rapid, uncoordinated jerking movements affecting primarily the face, feet and hands - Results from childhood infection with Group A Strep and is reported to occur in 20-30% of patients with acute rheumatic fever (ARF) - The disease is usually latent, occurring up to 6 months after the acute infection, but may occasionally be the presenting symptom of rheumatic fever - more common in females than males and most patients are children, below 18 years of age. Usually resolve in several months.
Glasgow Coma Scale (GCS)
- is a neurological scale that aims to give a reliable, objective way of recording the conscious state of a person for initial as well as subsequent assessment. - initially used to assess level of consciousness after head injury, and the scale is now used right at the time of injury on site by first responders - In hospitals it is also used in monitoring chronic patients in intensive care • The GOLD STANDARD used to document level of consciousness post TBI and now in ICU pt's as well
Types of wheelchair armrests: tubular
- lighter weight, easier to manage independently by the patient, still supports weight to perform pressure reliefs. - Good for those that are independent and strong in the arms, also good for quads who are very active - Pt.'s who are doing independent transfers often - They can be removed from the w/c when wanted to allow better propelling mechanics without rubbing the inside of the arm and the receiver is light enough to not be detrimental. - Pt. can push up to relieve pressure
Weight distribution
- look for equal weight distribution between feet and symmetry of the trunk and extremities. - orient people to their feet, what are they feeling: toe's heels, all weight on one foot, etc. Rocking board in mirror is helpful to re-learn proper weight distribution
Velocity
- measurement of a body's motion in a given direction - can be calculated by taking the total distance (d) between the first and last heel strikes and dividing it by the elapsed time (td) for the distance (v=d/td)
Gait Analysis for Kinematic and kinetic Variables: Motion Analysis System
- most sophisticated and expensive way of determining jt displacement and patterns of motion. Markers are placed on body segments and tracked by automated systems. 2 major types of systems are available: 1. active markers (light-emitting diodes (LED) flash at given frequency 2. passive markers- need external source of illumination or infrared emitting diodes around lens of camera Problems: concern skin movement over the skeleton and the need to improve accuracy of derivation of joint centers. In the future MRI should prove valuable in locating the exact joint centers. - There are many kinds of motion analysis and DC clinical gait measurement systems. -peak motus -Ariel performance -Vicon motion analysis system -Ortho trak -ELITE plus
Intralimb coordination
- movements occurring within a single limb - alternately flexing or extending the elbow; use of one UE to brush the hair; or motor performance of a single lower extremity during a gait cycle
AM-PAC 6 clicks
- multidimensional measures that use 6 questions to assess functional outcomes of patients in postacute care settings - used with a variety of diagnoses and patient populations to measure basic mobility (with and without a stair-climbing option), daily activity, and applied cognitive functions - measures aspects such as difficulty, assistance, and limitations in activities of daily living. - short forms can be administered quickly to provide health care professionals with data to assist in predicting acute care hospital discharge destinations that can be entered into electronic medical records. • The basic mobility domain (short form) assesses difficulty or level of assistance needed with: •Bed mobility •Sit to stand; stand to sit •Supine to sit •Seated transfers •Ambulation •Ascending stairs
Frenkel Exercises
- originally developed to treat patients who had sensory ataxia due to a loss of proprioception. Require a high deal of concentration and patients learn to use cognitive strategies to overcome movement problems. *Teaches the patient to use vision as the principle source of feedback in guiding the adaptation to sensory perturbations, such as loss or diminished proprioception - Practiced smoothly and consistently. - Four basic postures: lying, sitting, standing and walking. - Progress to start and stop on command. - Concentration and repetition emphasized. - A patient treated with these exercises must, therefore, be able to see his/her limbs - Place the patient in a semi-fowler (half-lying) position or sitting; or place a mirror in front of the patient - Start with limb movement supported on the surface progressing to antigravity movements, and from unilateral movement to bilateral-symmetrical to bilateral-reciprocal - Should be performed in postures with the most stability and progressed to positions that challenge the patient's stability
Abnormal observations linked with tasks: Hypotonia
- passive movement (pendular knee swing) - Deep tendon reflexes
Abnormal observations linked with tasks: Rigidity
- passive movement/ROM - observation during functional activities - observation of resting posture(s)
ICF Model: Environmental Factors
- physical, social, and attitudinal environment in which people live and conduct their lives (social attitudes, architectural characteristics, legal and social structures) - Can have either a positive (enhancing function/participation) or negative (limiting function/participation) effect. - Critical because disability emerges from a complex relationship between factors in the individual and external factors reflecting the circumstances in which the person is living - Some environments facilitate functioning and reduce disability, while others restrict functioning and increase disability. Thus, determination of disability cannot be made solely by factors intrinsic to the individual; demands of the environment must be considered in the disabling process
Abnormal observations linked with tasks: Dysmetria
- pointing and past pointing - Drawing a circle or figure eight - heel on shin - placing feet on floor markers; sitting, or standing
Common knee deviations during the gait cycle: excess knee flexion
- possible causes: knee flexor spasticity or contracture that exceeds position required for given phase; painful or effused knee; proprioceptive loss at knee, shorter LE on contralateral side. Consider weak calf or hip flexion contracture if it occurs during single limb support. - Analysis: examine tone, spasticity and ROM; and for pain, effusion, proprioceptive loss at knee; leg length discrepancy
Swan-Ganz catheter
- pulmonary artery catheter - indirect measurement of the pressure in the left atrium - measurement compares left and right cardiac activity and calculates preload and afterload flow and pressures which theoretically if stabilized or adjusted with drugs to either constrict or dilate the vessels to raise or lower the pressure of blood flow to the lungs, respectively, in order to maximize oxygen for delivery to the body tissues
Movement strategies for Balance: Stepping strategy
- realigns the BOS under the COM with large perturbation research suggests it isn't just the strategy of last resort. - They are often initiated well before the COM nears or exceeds the LOS
Direct impairment
- result of pathology or disease states and include any loss or abnormality of physiologic, anatomic, or psychological structure or function -Stroke: sensory loss, paresis, dyspraxia, hemianopia.
Attention
- selective awareness of the environment -Can test by repeating a series of numbers, letters, or words, spelling words backwards (WORLD, etc.)
Upper motor neuron syndrome (UMN)
- spasticity arising from injury to descending corticospinal pathways (pyramidal tracts) - Loss of inhibitory control on lower motor neurons results in: -Injury to descending motor pathways (pyramidal tracts) -Disinhibition of spinal reflexes -Hyperactive tonic stretch reflexes -Failure of reciprocal inhibition -Hyperexcitability of the alpha motor neuron pool - Abnormal movement patterns, associated reactions, clonus - Babinski sign - Associated reactions: involuntary movements resulting from activity occurring in other parts of the body (sneezing, yawning, squeezing the hand)
Function/ Task-oriented training
- specific task-oriented training with extensive practice is essential to reacquiring skill and enhancing recovery -Essential function tasks -Non-participating: lack voluntary control or cognitive f(n) - not appropriate for every pt. Depends on degree of recovery and severity of motor deficits *mimic their home environment/the outside work environment!
Documentation: Subjective
- state the information received from the pt that is relevant to the present condition ► Necessary to justify or explain certain goals that are set ► Acceptable to use "Pt" the first time, but do not repeat it every sentence. ► Items that belong: ►History (age, diagnosis, how injured)—From H&P also ►Lifestyle ►Home situation ►Emotion/attitude ►Complaint ►Personal goal
Motor learning
- study of acquisition and/or modification of movement. - Focuses on understanding the acquisition and/or modification of movement both the acquisition and the reacquisition of movement - a set of internal processes associated with practice leading to permanent changes in skilled behavior
Symptom
- subjective reaction to the physical abnormality - Knee pain, stiff feeling, lack of coordinated movement
Coordination
- the ability to execute smooth, accurate, controlled motor responses •sequencing •timing •grading of the activation of multiple muscle groups
Visual Motor Coordination
- the ability to integrate both visual and motor abilities with the environmental context to accomplish a goal - Tracing over a zigzag line, writing a letter, riding a bicycle, or driving an automobile
Power wheelchair proportional drive controls: head control
- the gimbal is mounted behind the head and attached to a headrest - pushes the left side of the headrest to go left, the right side to go right and pushes back to go forward. In order to back up the user must activate a switch and then push the headrest straight back
Patients with decerebrate posturing present with
- the head arched back, the arms are extended by the sides, and the legs are extended - A hallmark of decerebrate posturing is extended elbows - The arms and legs are extended and rotated internally - The patient is rigid, with the teeth clenched
Indirect impairment
- the sequelae or complications that originate from other systems - From preexisting impairments or expanding multisystem dysfunction from prolonged inactivity, lack of adherence to suggested strategies/interventions, an ineffective plan of care, or lack of rehabilitation intervention -example stroke: decreased vital capacity, disuse atrophy and weakness, contractures, decubitus ulcers, deep venous thrombosis, renal calculi, urinary tract infections, pneumonia, and depression.
24" wheelchair wheel
- the standard wheelchair wheel size - They are almost universally placed on wheelchairs, the advantage is that they are smaller and easier to transfer over than a larger wheel
POC for pt with impaired sensation utilizes
- theoretical approaches -Sensory Integration Approach -Compensatory Approach
26" wheelchair
- they must be a special order/or add-on to the wheelchair - The advantage is that for very tall people you can get a better arm stroke for more efficient propulsion, the other advantage is that you can buy replacement tires in a bike shop for less expensive than a medical supply shop - The disadvantage for the shorter person is that you have to get more shoulder flexion with each propulsion (wear out the shoulder faster), it is also a larger wheel to transfer over
Descending Motor Pathways: Corticospinal tract
- transmits signals from the motor cortex directly to the spinal cord, it is among the longest and largest CNS tracts. *Originates: Areas 4 and 6 (voluntary motor) - the sensory decussation occurs at the medulla oblongata • Corticobulbar tract • Tectospinal tract • Reticulospinal tract • Medial and Lateral • Vestibulospinal tract • Rubrospinal tract
Power wheelchair non-proportional drive controls: Sip'n'Puff Drive Control
- use for those who aren't able to use any part of their body to operate a control device on their power wheelchair - to be able to drive it, they must really be set up in latched so that somebody can drive without exhausting themselves. One command will be given and the chair will continue to react upon that request until the next command is given.
Behavioral shaping techniques
- use reinforcement and reward to promote skill development - Initial mvmts can be guided/assisted but the goal is ACTIVE Movements - represents a shift away from a traditional neurotherapeutic focus that utilizes extensive hands-on therapy (facilitated movements) such as NDT. the therapist serves as coach providing appropriate feedback and encouraging the patient
Power wheelchair non-proportional drive controls: Wafer board
- used on the user's lap or a wheelchair tray • an option for a user who has some control of a hand but can't maintain the constant control needed to operate a joystick
Abnormal observations linked with tasks: Disturbance of gait
- walk along a straight line (tight rope) - walk sideways, backwards - march in place - Alter speed and direction - Walk in a circle
Abnormal observations linked with tasks: Bradykinesia
- walking, observation of arm swing and trunk motions - walking, alter speed an direction - request that a movement or gait activity be stopped abruptly - observation of functional activities: timed tests
Movement and Action
- what functional actions are we asking our neurological patients to perform in rehab following a CNS insult? - walking - transfers - bed mobility - balance - reach
Measurement of spatial variables
-Degree of foot angle (5-7 degrees) -Step Width (7-10 cm) -Step length (.71 meters) -Stride length (1.42 m) ■ Men: 1.51 m ■ Women 1.32 m ■ Cadence (Mean) is 113 steps/minute -Men 108 steps/min -Women 118 steps/min ■ Velocity (Average) -Men: 1.37 m/sec (3 mi/hour) -Women: 1.30 m/sec (2.9 mi/hour)
PERRLA stands for
-Pupils -Equal -Round -Reactive to -Light and -Accommodation (ability of eyes to focus on objects that are close up and far away)
Neurological gait patterns are influenced by
1. Abnormal tone on jt position and mvmt 2. Head position on mm tone, position, mvmt 3. How does weight bearing influence tone, position and mvmt 4. Influence of obligatory synergistic activity 5. Impact of weakness (paresis) 6. Incoordination 7. Decreased balance reactions 8. Contractures 9. Sensory loss
Initial contact is __________ of the gait cycle
0-2%
Stance phase is __________ of the gait cycle
0-62%
Screenings are to:
1) Determine the need for further or more detailed examination 2) Rule out or differentiate specific system involvement 3 )Determine if referral to another health care practitioner is warranted 4) Focus the search for the origin of symptoms to a specific location or body part 5) Identify system-related impairments that contribute to activity limitation or disability
Preliminary things to test for before a sensory examination:
1. Arousal level, Attention, Orientation, and Cognition 2. Memory, Hearing, and Visual Acuity
Numbness on the ulnar half of ring finger, little finger, ulnar side of hand could indicate
1. C8 and T1 (ulnar nerve)-Problems originating at the neck: thoracic outlet syndrome, cervical spine pathology, tight anterior scalene muscles. • Problems originating in the chest: tight pectoralis minor muscles Brachial plexus abnormalities. • Elbow pathology: fractures, growth plate injuries, cubital tunnel syndrome, • Forearm pathology: tight flexor carpi ulnaris muscles • Wrist pathology: fractures, ulnar tunnel syndrome, hypothenar hammer syndrome
Functional reach test score interpretation
1. Community Dwelling Elderly < 7 inches= (limited mobility skills, restricted ADL's) 2. Frail Elderly 7.3 inches= fall risk 3. Parkinson's Disease 10 inches= fall risk 4. Stroke 6 inches= fall risk
Factors that may affect Motor Exam:
1. Consciousness and Arousal 2. Cognition 3. Sensory Integrity and Integration (sensory exam comes first) 4. Joint integrity, positional alignment and mobility
Patient/Client Management
1. Examination of the patient 2. Evaluation of the data and identification of problems 3. Determination of the diagnosis 4. Determination of the prognosis and plan of care (POC) 5. Implementation of the POC (Intervention) 6. Reexamination of the patient and evaluation of treatment outcomes
Nonequilibrium Coordination Tests
1. Finger-to-nose 2. Finger-to-therapist finger 3. Finger-to-finger 4. Alternate nose to finger* (dysmetria) 5. Finger opposition* 6. Mass grasp 7. Pronation/supination* dydiadochokinesia 8. Rebound test 9. Tapping (hand) 10. Tapping (foot) 11. Pointing and past pointing 12. Alternate heel-to-knee; heel to toe (S) 13. Toe to examiner's finger (S) 14. Heel on shin* (S) (dysmetria) 15. Drawing a circle with UE or LE(S) 16. Fixation or position holding (S)=supine *=most often performed >Tests should be performed with eyes open and then with eyes closed.
Ways to test cognition
1. Fund of knowledge - sum total of an individual's learning and experience in life. (e.g. what state is Boston in, who became president after Kennedy was shot, who is the VP of the US) 2. Calculation ability - initiate with simple, advance to more difficult. Mental or on paper (4+4=) 3. Proverb Interpretation - ability to interpret use of words outside of their usual context or meaning. (e.g. People who live in glass houses shouldn't throw stones, a stitch in time saves nine)
Elements of the Motor Function Exam
1. Tone 2. Reflex Integrity 3. Cranial Nerve Integrity 4. Activity-based task analysis
Mid Stance is __________ of the gait cycle
12-31%
Goal Writing - ABCD Method
1. Individual (Audience) ►Who will perform the specific behavior? (Who) 2. Behavior/Activity ►What behavior or activity will be demonstrated? (Will do what) -goals and outcomes include changes in: impairments (ROM, strength, balance) activity limitations (transfers, ambulation, ADL) participation restrictions (community mobility, return to school or work) 3. Condition ►Specific condition under which the behavior is measured? (Under what conditions, How well)—book talks about FIM (now Care Tool) -Distance achieved, required time to perform the activity, the specific number of successful attempts out of a specific number of trails. The type of environment required for a successful outcome of the behavior should also be specified: clinic, home, community 4. Time (Degree) How long will it take to achieve the goal (short or long-term goals/outcomes. Short-term (1-3 weeks), long-term (longer than 3 weeks or discharge—outcomes describe the expected level of functional performance attained at the end of the episode of care or rehabilitation stay)
There should be a ________________ bend at the elbow when using crutches
15-30 degree
Prognosis
1. Predicted optimal level of improvement in function 2. The amount of time needed to get there ► An accurate ________________ may be determined at the onset of tx. ► Complicated patients with extensive disability and multisystem involvement (e.g., TBI, CVA, SCI), a ______________ or prediction of level of improvement can be determined only at various increments during the course of rehabilitation
Sensory testing equipment
1. Safety pin or large paper clip (Pain) 2. Two laboratory test tubes with stoppers or "Tip Therm" (Temperature) 3. A camel hair brush, piece of cotton or tissue. (Touch) 4. Tuning fork,128 Hz. (Vibration) 5. Comb, fork, paper clip, key, coin, pencil, etc. (Stereognosis) 6. Aesthesiometer (Two-point discrimination) 7. Fabrics of various textures: cotton, wool, silk (approx 4 x 4 in.) (Texture recognition) 8. A set of discrimination weights. (Barognosis)
Directions for Performing an OGA
1. Select the area pt will walk, measure distance 2. Position video camera to get head to toes (sagittal and coronal perspectives) 3. Select joint or segment to be observed 4. Select sagittal or frontal plane to observe first (but observe all planes) 5. Observe segment during initial part of stance phase and make decision re: position of segment (pick a reference limb and watch it throughout the cycle) 6. Observe either the same segment during the next part of the stance phase or another segment at the initial part of stance 7. Repeat until observation is complete 8. Observe from both left and right.
Balance emerges from complex interaction of:
1. Sensory/perceptual (Vision, somatosensation, vestibular) 2. Motor System to execute motor synergies 3. Higher-level CNS processes (integration and action plans)
Stance is the most challenging task in the GC because 3 functional demands must be satisfied:
1. Shock absorption 2. Initial limb stability 3. The preservation of progression - The challenges is the abrupt transfer of body weight onto a limb that has just finished swinging forward and has an unstable alignment. Two gait phases are involved, IC and loading response.
Uninvolved stance time
The length of time up to 30 seconds that an individual can stand in the parallel bars while bearing weight on the uninvolved LE (SLS)
3 types of sensory receptors
1. Superficial 2. Deep 3. Combined Cortical Sensation
The motor cortex receives info from 3 primary sources:
1. somatosensory cortex (peripheral receptive fields-cutaneous sensations, joint and mm receptors) 2. cerebellum 3. basal ganglia
The use of diagnostic categories specific to PT allows:
1. successful communication with colleagues/pt/caregivers; 2. appropriate classification for standards of exam and tx; 3. directs exam of tx effectiveness, enhancing evidence-based practice. (Also, facilitates successful reimbursement when linked to functional outcomes and enhances direct access of physical therapy services.
What are the 3 critical sensory systems for balance?
1. visual 2. somatosensory 3. vestibular *Each system provides unique info and no one system provides all the information needed
Normal gait speed range
1.2 m/sec -1.4 m/sec
The average stride length of normal adult females
1.28 meters
The average stride length of normal adult males
1.46 meters
Loading Response is __________ of the gait cycle
2-12%
Initial Swing is __________ of the swing phase
2-75%
Gait speed required to safely cross the street
3 feet/sec
The different sizes of wheelchair drive wheels
20", 24", 26"
On the MoCA, a score of ______________ is normal
26 or above
Terminal Stance is __________ of the gait cycle
31-50%
Gait speed that suggests an increased risk for falling
34 m/min
Stance phase of the gait cycle
60% in which the foot of the reference extremity is in contact with the ground (first 5 phases of gait)
The typical hanging angle for front rigging on a wheelchair is
60-110 degrees (will depends on patient needs)
Swing phases are __________ of the gait cycle
62%-100%
A PT must determine plan of care for a complicated patient with multiple comorbidities within ____________ of admission to a rehab facility
72 hrs
Swing phase of the gait cycle
40% in which the reference extremity does not contact the ground. (Last 3 phases of gait)
Healthy range for 6 min walk test
400-700 meters
Pre-Swing is __________ of the gait cycle
50-62%
Number of conditions in the CTSIB
6
Hoffman Sign
A finding elicited by a reflex test which verifies the presence or absence of problems in the corticospinal tract. It is also known as the finger flexor reflex. The test involves tapping the nail or flicking the terminal phalanx of the third or fourth finger. A positive response is seen with flexion of the terminal phalanx of the thumb.
What does somebody look like that has poor motor control?
A patient that has very poor coordination, impaired balance reactions, and unable to control forward or rear loss of balance
Pre-Swing (PSw) is described as
A rapid unloading of the limb occurs as weight is transferred to the contralateral limb, the second period of double limb support.
Plan of care (POC)
A. Goals and expected outcomes B. Prognosis (Predicted level of optimal improvement) C. Specific interventions to be used (type, duration, frequency) D. Anticipated discharge plans - Outlines anticipated patient management - The therapists evaluates and integrates data from: 1. Hx, 2. systems review, 3. tests and measures, - In the context of other factors: Overall health, availability of social support systems, living environment, potential discharge destination - Multisystem involvement, severe impairments and functional loss, extended time of involvement (chronicity), multiple co-morbid conditions, and medical stability of the patient are important parameters that increase the complexity of the decision making process.
Subdivision of Coordination Tests
A. Nonequilibrium Tests • Components of limb mvmt B. Equilibrium Tests • Balance tests- static and dynamic
Capacity
Ability to execute a task or action (highest level of functioning)
Motor skills: mobility
Ability to move from one position to another - failure to initiate or sustain mvmts through the range; poorly controlled movements
Lesions to the Cerebellum, Basal Ganglia, and Dorsal column-medial lemniscal pathway
Affect higher-level processing and execution of coordinated motor responses
PT interventions for muscle tone
Altering a patient's position
Heel rocker
As body weight is dropped onto the stance limb, the heel acts as a fulcrum and rolls the limb forward. Pre-tibial muscles decelerate foot drop, also drawing the tibia forward
Forefoot rocker
As the heel rises the fulcrum for tibial advancement shifts to the metatarsal heads. Progression is accelerated as body weight falls beyond the area of foot support.
What are some of the dexterity tasks that are functionally important?
Buttoning shirt, tying shoes, using key in a lock, picking up small objects, etc.
Goals
Define the interim steps that are necessary to achieve expected outcomes
Numbness on the palmar surface of thumb, palmar and distal dorsal aspect of index, middle and radial half of ring finger could indicate
C6-8, T1 (median nerve)--Median nerve palsy is often caused by deep, penetrating injuries to the arm, forearm, or wrist. It may also occur from blunt force trauma or neuropathy
____________ is responsible for the sensory portion of the gag reflex
CN IX
____________ is responsible for the motor portion of the gag reflex
CN X
Postural alignment
COM occurs at a point above 2/3 of the body height above the BOS . Line of gravity (LOG) slightly anterior to ankle and knee, slightly posterior to hip, thru midline of trunk just ant. to shoulder joint, through external auditory meatus.
ICF Model: Personal Factors
Can include those such as age, education, socioeconomic status, and presence of other co-morbidities. Other examples include lifestyle and health behaviors such as exercise and diet; psychosocial attributes such as positive affect, prayer, and selfefficacy; and the ability to adapt to and accommodate potential limitations
_____________________ are the outcome of clinical reasoning process
Clinical decisions
Clinical Test of Sensory Interaction and Balance (CTSIB)
Condition 1: firm surface, eyes open Condition 2: firm surface, eyes closed Condition 3: firm surface, visual conflict Condition 4: compliant surface, eyes open Condition 5: compliant surface, eyes closed Condition 6: compliant surface, visual conflict - Patient Stands with hands at their sides, feet together: Test is terminated if pt's arms or feet change positions. If unable to complete on first trial, 2 additional attempts are allowed. The scores on the 3 trials are averaged.
Modified CTSIB
Condition 1: firm surface, eyes open Condition 2: firm surface, eyes open Condition 4: foam surface, eyes open Condition 5: foam surface, eyes closed
Assessment of trunk control
Consider: 1. Supine -> Sit in the home environment 2. Sitting EOB -> Stand at home 3. Ambulating down 5 steps with one handrail and then walking 200ft to the car 4. Transferring into the passenger seat of the car
_______________________________ may occur in the presence of normal ROM, strength, and intact sensation.
Coordination impairments
FITT equation (schema) for Exercise intervention
Frequency, Intensity, Time (duration), Type of intervention
Pathway of the Doral Column-Medial Lemniscal System
From dorsal roots of spinal n., ascend to medulla, synapse w/ dorsal column nuclei, cross to contralateral side and ascend to thalamus; project to sensory cortex
Pathway of the Anterolateral Spinothalamic tract
From dorsal roots of spinal n., synapse at dorsal horns, fibers cross and move up spinal cord, thru medulla, pons, and midbrain to the VPL nucleus of thalamus
Athetosis
involuntary writhing twisting, wormlike mvmts (rare alone, often seen with chorea)
If hyper-excitability, Babinski sign, and Clonus are present,
it is indicative of an UMN lesion
Grading deep tendon reflexes (DTR)
The main muscles tested are: - Jaw (CN V) - Biceps Musculocutaneous nerve (C 5, 6) - Brachioradialis (supinator Radial nerve C5, 6) - Triceps Radial nerve (C6, 7) - Finger flexors Median nerve (C6-T1) - Hamstrings Tibial branch, sciatic nerve (L5, S1, S2) - Quadriceps (patellar, knee jerk) Femoral nerve (L2, L3, L4) - Achilles (ankle jerk) Tibial S1-S2)
Initial Contact (IC) is described as
The moment when the foot contacts the ground
Kinesthesia
Detecting movement in space
Two Terms often associated with coordination:
Dexterity and agility
"Stocking numbness" in hands/feet could indicate
Diabetic neuropathy or MS
Movement strategies for Balance
Fixed support strategies (mvmt strategies to control COM over fixed BOS)
_________________ may be the sole focus of a profile or the gait analysis may constitute only a small portion of a broad examination profile that includes balance skills and other functional activities
Gait analyses
Two steps, a right step and a left step comprise a stride and a stride is equal to a __________________
Gait cycle
___________________________________________________ are not performed if stereognosis and 2-pt discrimination are intact
Graphesthesia, Barognosis and texture recognition
Time (duration)
How long will the pt receive skilled care? (eg 3x per week for 6 weeks or 2x/day for 3-4 weeks)
Frequency
How often the patient will receive skilled care? (times per day, per week, or # of visits before a certain date)
Gait Cycle Divisions
I. Initial double limb stance begins the GC. IC initiates the first period, (double limb support is an old designation to be avoided, however, as it implies an equal sharing of body weight by the 2 feet). II. SLS (single limb support) begins when the opposite foot is lifted for swing. Keeping with terminology: for double contact periods, this should be called single stance, to emphasize the functional significance of floor contact by just one foot, the term support is preferred III. Terminal double limb stance. Begins with floor contact by the other foot and continues until the original stance limb is lifted for swing. The term terminal double limb support has been avoided as weight bearing is very asymmetrical. ●Note: right SLS is the same time interval as left swing.
Front-wheel drive wheelchairs
In this type of chair, the drive wheels are actually forward of where you sit. It is a very stable set-up for uneven terrain, up and down hills. Out of the three types, it climbs forward over small obstacles best. Most of the chair is in back of you, so when turning, you have to be aware of what is behind you. The driving characteristics can be compared to a forklift. The overall speeds are slower (about 5 to 5 ½ mph) because the front-wheel drive tends to "fish tail" at higher, more reactive speeds. The overall turning radius is about 25 to 28", depending on the manufacturer. Front-wheel drive wheelchairs tend to be used less than the others because the lower driving speed you must maintain to prevent feeling unstable with the "fish-tailing"
Testing hearing
Observe patient's response to conversation. How alterations in voice volume and tone influence patient response
____________ is the last phase of stance: sometimes called terminal double limb stance or push-off
Pre-swing
Cerebellar Treatment: General techniques
Probably the most frequently used technique to improve coordinated movement is repetition and practice of a functional task-specific movement. Since the requirement for accuracy creates increasing demands for coordination, therapists can select functional tasks with increasing accuracy demands when training the patient. To assist the patient in recognizing errors in performance of coordinated movement, the therapist can provide feedback (either knowledge of results or knowledge of performance)
Cognition
Process of knowing; includes awareness and judgment
Terminal Stance (TSt) is described as
Progression over the stance limb continues. The body moves ahead of the limb and weight is transferred onto the forefoot
________________ gait analysis is the most common method used in clinical settings
Qualitative
Treatment of Involuntary Movements
Rehabilitation strategies for treating involuntary movement focus primarily on strategies to compensate for the movement, rather than on changing the movement itself. For example, since increased effort tends to magnify involuntary movements, patients can be taught to perform functional movements with reduced effort. Patients often tend to develop compensatory strategies on their own, such as walking with hands in pockets, or grasping objects to decrease resting tremor. Weight bearing and approximation have been recommended as a method to increase joint stability in patients with chorea or athetosis. Distal fixation is another method used to control involuntary movements and can be achieved by providing external handholds on wheelchairs, lap boards, or desks
Sensory homunculus
Representation of different areas of body for tactile discrimination
Lifting the other foot for swing begins the
SLS interval for the stance limb -This continues until the opposite foot again contacts the floor. During the resulting interval, the one limb has the total responsibility for supporting body weight in both the sagittal and coronal planes while progression continues. 2 phases are involved in SLS: midstance and terminal stance.
Loading Response (LR) is described as
Weight is rapidly transferred onto the outstretched limb, the first period of double-limb support (along with IC)
Type of intervention
What are the specific exercise strategies or procedural interventions used? (NMES to DF, gait training, mobility training, family training, etc.)
Oculomotor Performance: Saccades
Sitting, keeping the head still and when verbally prompted, client alternately fixes gaze on one of two pen tips, or a pen tip and the examiner's nose, or other small objects. Vary the target (pen tip) locations, testing a variety of end point locations, directions of movement, and distances traveled, including full range of motion. Observe for dysmetria, particularly on initial trials.
Oculomotor Performance: Smooth pursuit
Sitting, keeping the head still, client follows pen tip or similar small object with eyes. Test in all movement planes and directions and through full range of motion. Vary speed. Observe for saccadic (choppy) pursuit.
Oculomotor Performance: Gaze-evoked nystagmus
Sitting, keeping the head still, client maintains gaze in a variety of locations, including near end ranges of lateral gaze. Observe for nystagmus, particularly toward the direction of gaze.
Neologisms
nonsense words
A score of < .4 m/s on the 10MWT indicates
household ambulation
Acute UMN lesions produce temporary _________________
hypotonia
Equilibrium tests
are followed by nonequilibrium tests • Both static and dynamic components of posture and balance when the patient is in an upright (sitting/standing) posture. • Primarily gross motor activities. Require observation of the body in both static and dynamic postures. • Sitting • Standing • Walking • Stairs
Electrogoniometers
joint displacement measured. Two rigid links connected by potentiometer that converts mvmt into electrical signal proportional to degree of mvmt. $3000 are most convenient and least costly means of measuring knee and ankle motion during walking.
Balance
The condition in which all the forces acting on the body are balanced such that the center of mass (COM) is within the boundaries of the base of support (BOS)
Location of sensory receptors (sensory nerve endings)
The distal end of an afferent nerve fiber
Movement emerges from
The individual, task, and environment
Ankle rocker
The ankle becomes the fulcrum once the forefoot strikes the ground. Tibial progression is controlled by eccentric contraction of the soleus.
Terminal Swing (TSw) is described as
The knee extends; the limb prepares to contact the ground for Initial Contact
Wheelchair spokes
Spokes, carbon, mags
Midstance (MSt) is described as
The body progresses over a single, stable limb
Sensory Organization Test Condition (SOT or CTSIB)
Testing procedure: -Shoes removed -Feet together, ankle bones touching -Arms crossed on chest, hands touching your shoulders 30 second trials -Subjective patient complaints are documented -Postural strategies used are documented (ankle, hip, arms, arms widen or elevated) -Stop test if patient alters the posture (widens or moves feet, opens eyes) or loses balance (requiring manual assistance) or steps (conditions 4, 5, 6 are on a 3" high density foam cushion) *Document 1 = min sway 2 = mild sway 3 = moderate sway 4 = fall
Production of Coordinated Movement
The Cerebellum, Basal Ganglia, and Dorsal column-medial lemniscal pathway input to and act together with the cortex
Initial Swing (ISw) is described as
The thigh begins to advance as the foot comes up off the floor
Mid Swing (MSw) is described as
The thigh continues to advance as the knee begins to extend; the foot clears the ground
Double limb support of the gait cycle
There are two intervals in a gait cycle in which body weight is transferred from one foot to the other and both right and left feet are in contact with the ground at the same time
Rear-wheel drive wheelchairs
This old standby is really one of the most stable chairs in most instances. However, going up steep hills will cause the chair to lean back on its anti-tip tubes to assist in preventing the chair from tipping backward. This type of chair has the highest top speeds available (about 6 mph). It also has the largest turning radius, beginning at about 30-33". If you have been driving a rear-wheel drive chair and plan to buy another type, keep in mind that the tie-down you use in your van will have to be re-made or replaced for the new style chair. The majority of people who order rear-wheel drives these days are people that started using them when they were the only option and they have a hard time feeling comfortable with something new and different. They are the best for long distances and higher speeds.
___________________________________ are the foundations of movement
Trunk mobility and stability
Kinetic gait analysis
Used to determine the forces involved in gait (more used with prosthetics)
Mid-wheel drive wheelchairs
Your center of gravity is about even with the center of the drive wheel in a mid-wheel drive chair, so the drive wheels essentially are under the user. You end up with equal parts of the chair in front of and behind your body. This type of chair is maneuverable in small spaces, with a turning radius of 20 to 26", depending on the manufacturer. Overall speeds are limited to about 5 ½ mph. Another consideration is terrain. When riding on uneven terrain or up and down curb cuts with a steep transition, there is a possibility of getting "stuck" on the front or rear casters, suspending the drive wheels so they have no contact with the ground. The majority of new users the last 5 years at least, all go home with a mid-wheel drive chair. When it comes down to it, most people chose what they first trial. Most of the trial or demo wheelchairs are midwheel drive chairs because of the advantage of the innate driving feel, the smaller turning radius, the smaller profile of the chair, the less "disabled look".
Entire limb (arm/leg) numb could indicate
a CVA
To stabilize the lower thoracic and lumbar spine,
a complex synergy between the diaphragm, pelvic floor, abdominal wall and spinal extensors is essential.
Free speed
a person's normal walking speed
Speed
a scalar quantity that has magnitude but not direction
Postural Assessment Scale for Stroke Patients (PASS)
a score of 32 is normal
Intact Up to C6 intact on right, up to C8 intact on left could indicate
a spinal cord injury (SCI)
Guttural
a term used to describe any of several speech sounds whose primary place of articulation is near the back of the oral cavity.
Ataxic limbs can be controlled by
light weights to stabilize movements, Velcro cuff weights (wrist or ankle), weighted boots or weighted jacket or belt can reduce tremors of limbs or trunk. Weighted canes or walkers can be used.
Movement accuracy
ability to gauge or judge distance and speed of voluntary movement
Transitional mobility
ability to move from one posture to another. BOS an COM changing!!
Sensory integration
ability to organize, interpret, and use sensory information (Not directly observable), alter their motor response
Alternate or reciprocal motion
ability to reverse mvmt between opposing mm groups.
Wheelchair back: Sling upholstery
lighter, adjustable tension upholstery, can be adjusted to insure less sag to help with posture
Hyperkinesis/hypokinesis
abnormal increased muscle activity or mvmt/decreased motor response especially to a specific stimulus
Modified Ashworth Scale
adds a 1+ scoring category to indicate resistance through less than half of the movement
Radial button
major deviation can more commonly be identified in that phase of gait and at that joint
Swing time
amt of time during the gait cycle that one foot is off the ground. Measure separately for R and L
Cycle time
amt of time required to complete a gait cycle. Measured in seconds.
Double limb support time
amt of time spent in the gait cycle when both lower extremities are in contact with the supporting surface. Measured in seconds.
Step time
amt of time that elapses between consecutive right and left foot contacts. Msmt in seconds
Stride time
amt of time that elapses during one stride; that is, from one foot contact until the next contact of same foot. Measurement is usually in seconds.
Abnormal posturing
an involuntary flexion or extension of the arms and legs, indicating severe brain injury. It occurs when one set of muscles becomes incapacitated while the opposing set is not, and an external stimulus such as pain causes the working set of muscles to contract.[1] The posturing may also occur without a stimulus.[2] Since posturing is an important indicator of the amount of damage that has occurred to the brain, it is used by medical professionals to measure the severity of a coma with the Glasgow Coma Scale
Body structures
anatomical parts of the body such as organs, limbs, and their components
Spasticity increases with
any noxious stimuli
In gait, a loss of control over the sequential timing of muscular activity may result in
asymmetrical step and stride lengths, inability to place foot where they want to, walking with a narrow base of support that increases likelihood of tripping over opposite foot, increasing instability, decreasing ability to catch themselves, etc.
Compensation
behavioral substitution, that is, alternative behavioral strategies are adopted to complete a task
Types of wheelchair armrests: full/desk length
better support for the arm especially if a tray is placed to keep arm elevated and in the visual field as in a quad quadriplegic or a CVA
Dementia
broad-based memory impairments and learning
For stroke patients, scoring __________ on the TUG indicates a fall risk
more than 15 seconds
PT should ideally choose interventions that accomplish
more than one goal and are linked to the expected outcomes
Kneeling and half-kneeling
can break up LE tone, can do balance activities in this position
Applied techniques for muscle tone management
can help break synergistic patterns
Consideration for asymmetrical sitting posture
clasp hands and bring them out front to make standing more challenging
Even though a patient might be in a ____________, they might still be able to feel or hear you
coma -Patients who were in a coma and later, upon waking, can relate what people were talking about around them - Always talk to them and describe what you am doing as if they were completely there and hearing everything that goes on around them -You need to always be encouraging, supportive, friendly, kind, etc. -Educate families that if they have arguments or talking about the poor prognosis, please leave the room to have these conversations.
A score of >.8 m/s on the 10MWT indicates
community ambulation
A sensory screening should:
• Indicate the need for more detailed testing • Help narrow the origin of symptoms • Provide insight into the cause of activity limitations
Decerebrate rigidity indicates a
corticospinal lesion in the brainstem between the superior colliculus and vestibular nucleus (lower level of brainstem also involved)
Decorticate rigidity is indicative of a
corticospinal tract lesion at the level of diencephalon (above the superior colliculus)
Clonus
cyclical, spasmodic alternation of muscular contraction and relaxation in response to sustained stretch of a spastic muscle
Bradykinesia
decreased amplitude and velocity of voluntary movement (seen with Parkinson's)
Extinction Phenomena
describes a situation in which only the proximal stimulus is perceived, with "extinction" of the distal
Adaptive wheelchairs
different positioning, weight bearing, psychological benefits, accessing their environment, can help venous and arterial sufficiency
Significant memory deficits can also seen in patient with
diffuse encephalopathies, bilateral temporal lesions and korsakoff's psychosis (thiamine deficiency)
Clonus should be assessed
during tone/spasticity assessment
Medullary reticulospinal tract
excitation of flexor motor neurons
Pontine reticulospinal tract
extension of LE (excitation of extensor motor neurons)---posture and gait
Persistent vegetative state
eyes open spontaneously, sleep/ wake cycles present, no evidence of awareness of self or environment, inability to act with others, no language comprehension or expression, no purposeful movement, no visual pursuit, bowel/bladder incontinence, variably preserved cranial nerve function
Movement strategies for Balance: Change-in-support strategy
fast, large postural perturbations when ankle and hip strategies are not adequate to recover balance
Abnormal observations linked with tasks: Asthenia
fixation or position holding (UE and / or LE) application of manual resistance to determine ability to hold
5x sit to stand cut off score
for predicting recurrent fallers - 15 seconds
Bed Mobility: Hooklying
for rigid individuals
Asthenia
generalized mm weakness
Peripheral nerve injuries
generally present sensory impairments that parallel the distribution of the involved nerve and correspond to its pattern of innervation
Sitting balance and posture
get them into an upright/erect posture
Corticobulbar tract
go to cranial nerve nuclei (trigeminal, facial, hypoglossal)
Types of wheelchair armrests: removable
good to allow easier transfers
Cerebellar Treatment: Use of weight-bearing activities
has also been recommended for improving coordinated action in the lower extremities. In addition to functional movements, therapists often have patients practice nonfunctional movements to improve coordination. Examples of nonfunctional movements are rapid alternating movements, reciprocal movements of the hands or feet, and tracing shapes and numbers, such as a figure 8, with a limb.
Wheelchair back: rigid inserts
heavy, however, they can maintain good posture with a lumbar support, laterals, more or less recline, etc
Diagnoses that may affect vision
hypertension, diabetes, MS
Medical diagnosis
identification of a disease, disorder, or condition (pathology/pathophysiology) by evaluating the cluster of signs & symptoms, history, laboratory test results, and procedure
Minimal conciousness
if one or more is met: follows simple commands, gestures or verbal yes/no, intelligible verbalization, purposeful behavior not a result of a reflex
PT diagnosis
impact of a condition on function at the level of the system (especially the movement system) and at the level of the whole person.
Dysdiadochokinesia
impaired ability to perform rapid alternating movements (RAM)
The most consistent characteristics of ataxic dysarthria
impaired articulation (the correct pronouncement of speech sounds) and impaired prosody (the pattern of stress and intonation of certain syllables or words). Other common findings include slowed speech and either a lack of or excessive loudness variability. Traditionally, speech impairments are treated primarily by speech and language pathologists.
Quadruped and moving in and out of sitting
important for fall recovery, can break up tone also
Static control exercises for treating cerebellar deficits
in weight bearing, antigravity postures (sitting, quadruped, kneeling, plantigrade and standing). Progression through a series of postures is used to gradually increase postural demands by varying BOS, raising COM and increasing the number of body segments or degrees of freedom.
Rebound Phenomenon
inability to halt forceful movements after resistive stimulus removed; unable to stop sudden limb motion
Akinesia
inability to initiate movement (Parkinson's disease "freezing")
Romberg sign
inability to maintain an upright posture without visual input - Record results per minute - Also grading scales: 4= normal performance 3= mvmt accomplished with only slight difficulty 2= moderate difficulty 1= severe difficulty 0= pt unable to accomplish activity
Delayed Reaction Time
increased time required to initiate voluntary mvmt
Participation restriction
individual's involvement in a life situation, the societal perspective of functioning. (life roles, job, school, leisure)
Somatosensation
information received from skin and musculoskeletal system (joint receptors)
Maintaining normal background muscle tone is accomplished by the
inhibitory effect of the basal ganglia on both the motor cortex and lower brainstem
Motor memory includes:
initial movt conditions, sensory feel of the movt, movement performance (KP), outcome of the movement (KR)
Tremor
involuntary oscillatory mvmt resulting from alternate contractions of opposing mm groups
Chorea
involuntary rapid irregular jerky mvmts involving multiple jts (UE's) (Huntington's)
Companion wheelchair
is the pt. going to have a care taker that will be pushing the wheelchair for them? this wheelchair is set up more for the ease of the care givers use
Hemiballismus
large-amplitude sudden, violent, flailing motions of the arm and leg of one side of body (contralateral subthalamic nucleus)
Parallel bar ambulation
length of time required for an individual to walk the length of the parallel bars as rapidly as possible. Two trials are averaged to obtain this measure. Measured in seconds.
Bilateral stance time
length of time up to 30 seconds that a person can stand upright in the parallel bars bearing weight on both LE
Involved stance time
length of time up to 30 seconds that an individual can stand in the parallel bars on the involved LE
A score of 4-.8 m/s on the 10MWT indicates
limited community ambulation
Asynergia
loss of ability to associate muscles together for complex mvmt
The cranial nerves are ____________________
lower motor neurons
Types of wheelchair armrests: trough/tray
may be able to play them to help with hand swelling, keeps the arm in the visual field, supports the arm
The Postural Stability Test
meets multiple clinical needs with a single tool
Glasgow Coma Scale (GCS) score of 13-15 indicates
mild or no brain injury
Preventative Interventions
minimizing potential impairments, functional limitations, and disabilities and maintaining health -Early standing on tilt table minimizes risk of pneumonia, teaching self stretching prevents flexion contracture, skin inspection and pressure changes prevents pressure ulcers
Paraphasias
misuse of words
Glasgow Coma Scale (GCS) score of 9-12 indicates
moderate brain injury
Adaptive Postural Control
modification of sensory and motor systems relative to task or environmental demands (moving sidewalk, treadmill increasing speed)
_______________________ is important in the neuro client because not only is the patient learning to walk with assistance, they need to learn to walk without my assistance or their family member. We have to insure that they "learn." Sending somebody home ambulating that is at a huge risk of falling can be catastrophic.
motor learning
Peripheral feedback during the motor response is provided by
muscle spindles, golgi tendon organs, joint and cutaneous receptors, the vestibular apparatus, and the eyes and ears.
Reticulospinal tract (medial and lateral)
muscle tone and reflex activity
Movement composition, or synergy
mvmt control achieved by muscles groups acting together
Choreoathetosis
mvmt disorder with features of both chorea and athetosis
Tectospinal tract
neck and IX spinal accessory (important in head movements during visual motor tasks)
Abnormal observations linked with tasks: Postural tremor
observation of steadiness of normal posture; sitting, standing
Proactive (anticipatory) Postural Control
occurs in anticipation of internally generated, destabilizing forces imposed on the body's own movements (such as when lifting a heavy object or catching a weighted ball).An individual's prior experiences allow the various elements of the postural control system to be pretuned or readied for upcoming mvmts using feed forward mechanisms.
Functional interventions
often the best kind, they are task-specific and meaningful to the patient
Intention tremor
oscillatory mvmt during voluntary motion; increases as the limb nears target; diminished or absent at rest
Assistive devices
parallel bars, walkers, axillary crutches, lofstrand crutches, canes to help keep a person mobile
Body function
physiological functions of the body systems (including psychological functions)
Arousal
physiological readiness of the human system for activity
Testing long term memory (remote memory)
place and date of birth, # of siblings, date of marriage, schools attended, number and names of children, etc
Impairments
problems in body functions or structure (significant deviation or loss)
Compensatory Interventions
promoting optimal function using residual abilities -T1 paraplegia learns to roll using upper extremities and momentum, L hemi learns to dress impaired side and use sock aide
Goal and outcome states should be
realistic, objective, measurable and time related
The richer the environment, the better the ________________
recovery
Hypotonia
reduced muscle tone or tension
Restorative interventions
remediating or improving the patient's status in terms of impairments, functional limitations, and recovery of function -incomplete SCI
Reactive Postural Control
response to external forces (such as perturbations acting on the body)—moving platform or therapy ball—Feedback systems provide the sensory inputs required to initiate corrective responses.
Nystagmus
rhythmic, quick, oscillatory, back-and-forth movement of the eyes
Motor learning and motor performance are linked to
sensation and our ability to perceive feedback -Feedback (sensory information during mvmt) -Feedforward (proactive strategy- sensory information from experience)
Proprioception
sense of body position
The _________________ provide the CNS with critical information about postural control and balance
sensory systems
The use of an assistive device
shows that people are slower, making it more difficult for community mobility. It also impacts in that slower gait speeds are more indicative of all the other problems: increased risk of falling, health risk, mortality, physical disability, etc.
Testing short term memory
series of words (3) to repeat back immediately for understanding, 5 minutes and 2/3 at 30 minutes.
Glasgow Coma Scale (GCS) score of < 8 indicates
severe brain injury and coma
Recovery of Function
similar to motor learning but with a twist: referred to the reacquisition of movement skills lost through injury
Dexterity
skillful use of the fingers during fine motor tasks
Dermatome
skin area supplied by one dorsal root. Pattern identification is accomplished using knowledge of skin segment innervation by the dorsal roots and peripheral nerves.
Disability
societal rather than individual functioning. Inability to perform or a limitation in the performance of actions, tasks, and activities usually expected in specific social roles that are customary for the individual or expected for the person's status or role in a specific sociocultural context and physical environment.:.....IE, self-care, home management, work (job/school play, community/leisure
Weight acceptance is the first task of ____________
stance
Quoting the patient verbatim may be most appropriate method of conveying __________________________ (show confusion, denial, attitude, use of abusive language)
subjective information -IE: What the pt/family tells you related to: ► History, chief complaints, functional level, social hx, living env/home set up, health habits, prior response to tx, previous interventions, goals etc.
A patient should feel __________________ after every therapy session
successful
True coma is ______________________________________
time limited (weeks), and there is no purposeful attention or cognitive responsiveness
Superficial cutaneous reflexes
• Light stroke applied to the skin. Contraction of muscle innervated by same spinal segments receiving the cutaneous input. • Babinski sign • Hoffman Sign • Abdominal (T8-12)
Speech
uses various strategies to facilitate recall of information (prompting, rehearsal, repetition, memory notebook)
Pallesthesia
vibratory sense
Circumlocutions
word substitution
Neuro examination: functional mobility
• Bed Mobility • Sitting (supported/unsupported) • Standing • Transfers • Gait • Stairs **Include level of assist, quality of movement, use of device and any cues that were required - Nursing relies on PT for this information ASAP
Functional training includes
• Bed Mobility • Sitting at the EOB • Standing at the EOB • Transfer to a chair • Ambulation
Standardized Measures (postural control and balance)
• Berg Balance Scale (BBS) • Performance Oriented Mobility Assessment (POMA)-Tinetti • Functional Reach (FR) • Multidirectional Reach Test (MDFR) • Timed Up and Go Test (TUG) and Get Up and Go (GUG) - Timed walking tests -Dynamic Gait Index (DGI)- -Functional Gait Assessment (FGA) -Timed walking test - Balance Test -Activities-Specific Balance Confidence (ABC) -Balance Efficacy Scale (BES)
Gross motor movements
• Body posture, balance, extremity movements involving large mm groups. Ex. crawling, kneeling, standing, walking, running
Inverted-U theory (Yerkes-Dodson law)
• Certain level of arousal is necessary for optimal motor performance • Very high or very low levels cause deterioration • Very high or very low may respond in unpredictable manner • This may help explain the reactions of pt's who are labile or lack homeostatic controls for normal functions.
Postural Orientation
• Control of the relative positions of body parts by skeletal muscles with respect to each other and gravity
Age-related sensory changes
• Degenerative changes in myelin, both CNS & PNS • Myelin of cortical neuron axons >> actual neuronal loss • Changes in conduction velocity, timing affected • Neurons replaced at declining rate. ↓ Postural stability & control ↓ Tactile, vibratory, proprioceptive responses. *Important to differentiate alterations in sensory function related to normal aging from those associated with specific illness, disease, or pathology. Also consider the combined effect on other senses (visual, vestibular, hearing) and medications.
Levels of rehab: Community rehab
• Designed for higher level patients with neurological impairments • Focus on high level dynamic balance activities and cognitive impairments • Goals to re-integrate patients into community setting
Levels of rehab: LTAC
• Designed for patient's with medical needs that are limiting progress or participation with therapy • Examples include vent weaning, complex co-morbidities (Dialysis, wound care, poor hemodynamic stability) • Patient's treatments are divided into short sessions multiple x/day • Anticipate length of stay will be >25 days - may be some gray area for lower level patients
Barognosis (recognition of weight) testing
• Discrimination weights- identical in size, shape, and texture, differ in graduated weight • Placement techniques: • Series of different weights in the same hand at one time • Place a different weight in each hand simultaneously • Ask the patient to use a fingertip grip to pick up each weight • Place the weights in a series or verbally compare the different weights ("heavier" or "lighter")
Neuro examination: cardiopulmonary
• Measure HR, BP, O2 saturation, RR • Assess response to activity (i.e. orthostasis) • Activity Tolerance • Pulmonary Assessment: •Cough •Secretions •Auscultation *especially important with SCI, or lower lever cognition
Olfactory Nerve (CN I)
• Distinguish Coffee from Cinnamon • Disorders of Smell result from closed head injuries, frontal lobe lesions • Test sense of smell on each side • No noxious odors - Sensory Function: Smell - Test: Test sense of smell on each side (close off other nostril): use common, nonirritating odors (lemon oil, coffee) - Possible Abnormal findings: anosmia (inability to detect smells), seen with frontal lobe lesions
Eye hand coordination—implications for ADLs
• Eating utensils • Personal hygiene • Reaching for a visual target
Formats of Documentation
• Examination •History •Systems Review •Test and Measures • Evaluation • Plan of Care
Oculomotor (CN III), Trochlear (CN IV), Abducens (CN VI)
• Extra-Ocular Muscles • Efferent limb of pupillary light reflex (III) • Ptosis Cardinal Directions of Gaze • Look for Nystagmus -"EOMI without nystagmus"(Extraocular muscles intact) - Function: extraocular mvmts - Test: saccadic (pt is asked to look in each direction) and pursuit eye mvmts (pt follows moving finger) - When testing these cranial nerves, have the patient sit with head still and follow your pen moving slowly up/down, right/ left and diagonal. Don't place the pen too close to the eyes or you are also testing convergence (II,III). - AbN: Strabismus (eye deviates from normal conjugate position), impaired eye mvmts, double vision
Three levels of function examined on the Glasgow Coma Scale (GCS)
• Eye Opening • Best Motor Response to a stimulus • Verbal Response
Primitive/Spinal Reflexes
• Flexor withdrawal • Crossed extension • Traction • Moro • Startle • Grasp
Cerebellum
• Function: regulation of movement, postural control, and muscle tone. • Lesions: produce typical patterns of impaired motor function and balance, and decreased muscle tone • Functions as a comparator and error-correcting mechanism
Facial Nerve (CN VII): Sensory Function
• Function: taste to anterior 2/3 of tongue, general sensation to concha of earlobe and small part of scalp - Test: apply saline solution and sugar solution using a cotton swab - AbN: incorrectly identifies solution
Activity-based Task Analysis
• Functional Measures •SOM's • Breaking a specific activity down into its component parts •Understanding of normal movement •Analyzes the differences compared to "typical" - Interpretation made about the nature of the motor performance, links between impairments and performance
Levels of rehab: SNF (sub-acute)
• Generally length of stay is longer than for sub-acute • Designed for patient's that are slow to progress or who have fair rehab potential • Example: 1. Patient requires minimal assist for ambulation of 25 feet. Progress limited by decreased activity tolerance or pt participation 2. At baseline patient transfers bed to chair only with minimal assist x 1, secondary to multiple co-morbidities. At time of evaluation, patient requiring maximal assist x 1 for transfers
Levels of rehab: Acute
• Generally pt need to tolerate 3 hours of therapy/day • Combined PT, OT, SLP • Pt may 'ramp up' to 3 hours while at rehab • Pt should have needs in at least 2 disciplines • Anticipate patient has good rehab potential • Generally neuro patient's who are independent PTA will qualify for this level of rehab
Testing visual acuity
• Gross exam (Snellen chart/ETDRS), peripheral field, visual field, depth perception.
Vestibulocochlear Nerve (CN VIII)
• Hearing and Balance - Patients will complain of tinnitus, hearing loss, and/or vertigo • Light whisper - hearing component -Weber and Rinne Test (512 Hz tuning fork) -Differentiates Conductive vs Sensorineural hearing loss • Vestibular - nystagmus • Afferent input to the Oculocephalic Reflex -VOR
Signs and symptoms of UMN Syndrome
• Hyperactive stretch reflexes • Involuntary flexor and extensor spasms • Clonus • Babinski sign • Exaggerated cutaneous reflexes • Loss of precise autonomic control • Co activation of agonist and antagonist mm groups • Abnormal timing • Paresis • Loss of dexterity • Fatigability
Neuro examination chart review should include:
• Mechanism of Injury • Tests/Procedures •Any x-rays, CT, MRI •Any surgical interventions, ICP placement trach placement • GCS or ASIA scale if applicable • Precautions: •Weight bearing, ROM, include specific limb/joint •Bracing (Cervical Collar, TLSO) •Activity Restrictions (Bed rest, bed to chair, as tolerated) •Blood pressure parameters • Past Medical History • Social History
Components of Motor Control
• Normal muscle tone • Normal postural response mechanisms • Selective movement • Coordination
The 3 divisions of the Trigeminal Nerve (CN V)
• Opthalmic (V1) • Maxillary (V2) • Mandibular Distributions (V3)
A GCS > 8 Evaluation will focus more on:
• Orientation • Safety • Attention • Balance • Coordination • Transfers/Gait
Documentation: Objective
• Paint a picture even for eval, every eval should include some part of intervention. - what the therapist observes, tests, or measures. Describes intervention completed. ► This information must be stated in measurable terms ► May be organized by specific headings: 1. Body systems 2. Types of specific tests and measures performed 3. Areas of the body and functional skills
Levels of rehab: Home
• Patient functioning at baseline status • Patient functioning close to baseline and able to be safely discharged (ambulating with walker with modified independence, however at baseline patient independent without device) • Patient requesting discharge home and family or caregiver able to safely provide necessary assistance • These services are indicated if patient would benefit from continued intervention to return to prior level of function (such as improving activity tolerance, progress gait to no device) ** Cognition, safety, and social support are very important
Hemodynamic Monitoring
• Patient will have continuous monitoring of ECG if in ICU • Continuous SpO2 (via finger, toe, ear) • BP cuff • May also have the following: •Arterial line (continuous) •Swan Ganz (continuous) •CVP (central venous pressure) monitor via central line (continuous) - Makes mobility more difficult, but gives you real time data about how a patient body is responding to treatment - Various restrictions on mobility per services and institutions
Type of intervention: Necessary components that should be identified include the following
• Posture and activity: specific posture and activity the patient must perform (sitting, weight shifting or standing, modified plantigrade, reaching) • Techniques used: therapist's assist (guided, active-assisted, resisted movement) or specific technique (rhythmic stabilization, dynamic reversals) • Motor learning strategies used: type of feedback, schedule of feedback, practice schedule and environment • Additional required elements: elements needed (verbal or manual cues, equipment-PBWSTT, elastic band, walker)
Levels of rehab: Acute-slow to recover
• Program is designed for patients with brain injuries who are in the minimally conscious state. • Pt not able to tolerate 3 hours/day • Generally initial goals include arousal, response to stimuli and tone management • Goal of rehab facility is to work with pt to progress to tolerate more conventional 'acute rehab' program
Double Simultaneous Stimulation
• Simultaneous and equal pressure touches on either identical locations on opposite sides, proximal and distal on opposite sides, or proximal and distal locations on the same side of the body
Variables impacting neuroplasticity
• Sleep • Mood • Hormones • Cardiorespiratory function • Fitness
Coordination depends on:
• Somatosensory input • Visual input • Vestibular input • Fully intact neuromuscular system from the motor cortex to the spinal cord - Appropriate speed, distance, direction, timing and muscular tension. - Appropriate synergistic influences and reversal between opposing muscles groups - Proximal fixation to allow distal motion (or maintenance of a posture, trunk control)
Hypertonia
• Spasticity • Rigidity • Decorticate and Decerebrate Rigidity • Dystonia
Equilibrium Coordination Tests (examples)
• Standing with narrowing BOS • Perturbations • Functional Reach Test • Romberg sign • Tandem walking • Observe different speeds of walking • Start and stop on command • Walk on heels or toes • Step around obstacles • Jumping jacks
An initial screening of ROM, Strength, and Sensation: might want to test a modality from each of the general categories:
• Superficial: light touch and pain • Deep: kinesthesia and vibration • Combined: 2-point discrimination or stereognosis
Mini-BesTest
• This test measures dynamic balance, functional mobility, and gait. • It is commonly used in populations who have or have had multiple sclerosis (MS), Parkinson disease (PD), strokes, spinal cord injury (SCI), or cancer. • 28 points, MCID is 4pts
Coordination tests can address patient capabilities in 4 basic areas of functional task requirements:
• Transitional Mobility • Stability (static postural control) • Dynamic postural control (Controlled Mobility) • Skill
Diagnoses that frequently have coordination impairments
• Traumatic Brain Injury • Parkinson's Disease • Multiple Sclerosis • Huntington's Disease • Cerebral Palsy • Sydenham's Chorea • Cerebellar Tumors • Vestibular Pathology • Some learning disabilities
ABC - Activities Specific Balance Confidence Scale (ABC)
• Used a lot to track progress or identify areas of fear/avoidance.
Persistent Vegetative State
• Used to describe individuals who remain in a minimally conscious (vegetative) state 1 year or longer after traumatic brain injury • Or individuals who remain 3 months or more for anoxic brain injury • Caused by SEVERE brain injury
Fine motor movements
• Utilization of small mm groups that involve skillful, controlled manipulation of objects • Buttoning a shirt, typing, handwriting
Somatotopic Organization of Motor Cortex
• Very similar to sensory cortex • Motor homunculus schematically illustrates the amount of cortical area devoted to motor control of a given body part or region.
The 3 Functional Tasks of Gait
■ 1. Weight acceptance -IC -LR ■ 2. Single limb support -MSt -TSt ■ 3. Swing limb advancement -PSw -ISw -MSw -TSw
Phase 2: Loading Response
■ 1st period of double limb support ■ B.W. transferred onto forward limb ■ Using heel as rocker, knee is flexed for shock absorption ■ Brief arc of PF interrupts heel impact - Interval 2 -12% GC - Objectives: ■Shock absorption ■Controlled weight transfer to stance limb ■Preservation of progression ■ Hip 20 degrees flex ■ Knee 15 degrees flex ■ Ankle 5 degrees PF ■ Toes 0 degrees -Active mm=pretibials, quads, hamstrings/gluts - Interval: this is the second phase contained in the initial double stance period. The phase follows the IC of the foot with the floor and continues until the other limb is lifted for swing
Phase 5: Pre-Swing
■ 2nd (terminal) double stance interval -Terminal double limb support initiated by floor contact of other limb ■ increased ankle PF, knee ✔; decreased hip extension ■Hip 10 degrees hyperextension (apparent) ■Knee 40 degrees flexion ■Ankle 15 degrees PF ■Toes 60 degrees MTP Ext -Interval: 50-62% GC -this final phase of stance is the second (terminal) double stance interval in the GC. It begins with IC of the opposite limb and ends with ipsilateral toe off. Weight release and weight transfer are other titles some investigators give to this phase. However, all the motions and muscle actions occurring at this time relate to progression. As the abrupt transfers of body weight rapidly unloads the limb, the trailing extremity contributes to progression with a forward "push" that also prepares the limb for the rapid demands of swing. -Objectives ■Position the limb for swing (thigh/knee flex) ■Accelerate progression
Instruments for testing gait variables
■ Accelerometers ■ Gyroscopes ■ GAITMAT II ■ Foot switch System ■ Electrogoniometers
Phase 7: Mid Swing
■ Advancement of limb gained by further hip flexion ■ Hip 25 degrees flexion ■ Knee 25 degrees flexion ■ Ankle 0 degrees ■ Toes 0 degrees -Interval 75-87% -this phase, the middle third of the swing period, begins as the swinging foot is opposite the stance limb. The phase ends when the swinging limb is forward and the tibia is vertical (ie hip and knee flexion postures are equal) -Objectives ■Thigh continues advancing ■Ankle DF to neutral for toe clearance
Gait cycle
■ Has both: -Spatial (distance) parameters -Temporal (time) parameters ■ Two phases: -1. Stance -2. Swing ■ Double Support x2 ■ Stride Length ■ Step Length *8 functional phases
Phase 4: Terminal Stance
■ Heel rises ■ Limb advances over the forefoot rocker ■ Hip 20 degrees hyperextension (apparent) (greatest hip extension point in the gait cycle) ■ Knee 5 degrees flexion ■ Ankle 10 degrees DF ■ Toes 30 degrees MTP Ext -Interval 31-50% -second half of SLS (single limb support). This phase complete SLS. It begins with heel rise and continues until the other foot strikes the ground. Body weight moves ahead of the forefoot throughout this phase. -Objectives ■Dynamic stability over the forefoot ■Controlled forward progression of the COM anterior to foot (forefoot rocker) - Knee completes extension (then begins a new arc of flexion - Increased hip extension and heel rise put the limb in a more trailing position. - Active muscle = Calf
Phase 1: Initial Contact
■ Hip 20 degrees flexion ■ Knee 5 degrees flexion* ■ Ankle 0 degrees ■ Toes 0 degrees ■ Interval: 0-2% GC - Objectives: -Heel contact to advance COM forward (heel rocker) -Impact deceleration -Active mm= pretibials, quads, hamstrings/gluts - This phase includes the instant the foot drops on the floor and the immediate reaction to the onset of body weight transfer. The joint postures present at this time determine the limb's loading response pattern
Phase 6: Initial Swing
■ Increased knee flexion, lifts foot for toe clearance ■ Hip flexion advances the limb ■ Hip 15 degrees flexion ■ Knee 60 degrees flexion ■ Ankle 5 degrees PF ■ Toes 0 degrees -Interval: 62-75% GC -the first phase of swing is approximately 1/3 of the swing period. It begins as the foot is lifted from the floor and ends when the swinging foot is opposite the stance foot -Objectives: ■Thigh advances forward ■Knee flexion to achieve toe clearance
Stance phases of the gait cycle
■ Initial Contact (IC) ■ Loading Response (LR) ■ Mid Stance (MSt) ■ Terminal Stance (TSt) ■ Pre-Swing (PSw)
Swing phases of gait
■ Initial Swing (ISw) ■ Mid Swing (MSw) ■ Terminal Swing (TSw)
Phase 8: Terminal Swing
■ Limb advancement completed by knee extension ■ Hip 20 degrees flexion ■ Knee 5 degrees ■ Ankle 0 degrees ■ Toes 0 degrees -Interval: 87-100% GC -this final phase of swing begins with a vertical tibia and ends when the foot strikes the floor. Limb advancement is completed as the leg (shank) moves ahead of the thigh. -Objectives ■Knee extends to prepare for heel contact
Phase 3: Mid Stance
■ Limb advances over the stationary foot by DF (ankle rocker) ■ Hip 0 degrees ■ Knee 5 degrees flexion ■ Ankle 5 degrees DF ■ Toes 0 degrees -Interval 12-31% GC -This is the first half of the SLS interval. It begins as the other foot is lifted and continues until body weight is aligned over the forefoot -Objectives: ■Controlled forward progression over the stationary foot (ankle rocker) ■Dynamic stability over the plantigrade foot - Active mm=calf, quads
Gait speed
■ Predict future health status, ease of administration, ease of grading and interpretation and minimal cost involved ■ Measure Comfortable gait speed (cgs) ■ Measure Fast/maximum gait speed (fgs) *34 m/min suggests increased risk for falling. It is accurately able to predict falls risk, determine health risk and mortality, predict discharge disposition and length of stay, define community ambulation and home bound status using objective quantifiable data makes gait speed a very powerful tool.
Quantitative Gait Analysis terms
■ Speed ■ Cadence ■ Velocity ■ Acceleration ■ Strike time ■ Step time ■ Stride length ■ Swing time ■ Double support time ■ Cycle Time (stride time) ■ Step length ■ Width of walking base ■ Foot angle ■ Bilateral stance time* ■ Uninvolved stance* time ■ Involved stance time* ■ Dynamic weight transfer rate* ■ Parallel bar ambulation*
Traditional phases of gait terminology
■ Stance Phase -Heel Strike -Foot flat -Midstance -Heel off -Toe off ■ Swing Phase -Acceleration -Midswing Deceleration
RLA phases of gait terminology
■ Stance Phase -Initial Contact (IC) -Loading response (LR) -Midstance (MSt) -Terminal stance (TSt) -Preswing (PSw) ■ Swing Phase -Initial swing (ISw) -Midswing (MSw) -Terminal swing (TSw)
Examination of variables in gait analysis
■ Step 1 - involves the identification and accurate description of the patient's gait pattern and any existing deviations ■ Step 2 - involves a determination of the causes of the deviations
Observational Gait Analysis
■ The Rancho Los Amigos Observational Gait Analysis (OGA) system is probably the most common OGA system used by PT's ■ Systematic examination of movement patterns of: ankle, foot, knee, hip, pelvis and trunk ■ System uses a recording form comprising defined descriptors
Calculations (10MWT)
■ Walking speed (velocity) -Distance÷Time -ie, 6 m ÷ 5 sec = 1.2 m/sec (60 sec/min)=72 m/sec ■ Cadence -Steps÷Time -Ie, 8 steps ÷ 5 sec (60 sec/min)=96 steps/min ■ Stride Length -Walking speed÷1/2 Cadence -ie, 72m/min ÷ (1/2 x 96 step/min)=1.5 m/stride
Documenting in a Medical Record
► Accuracy ►Never record falsely, exaggerate, underestimate, or make up data. ►Correct spelling, correct grammar, correct punctuation! ► Brevity ►Use short, succinct sentences ►Abbreviations help with brevity, must be generally accepted ► Clarity ►Meaning is immediately clear ►Sudden shifts in tense should be avoided
Categories for tests and measures
► Aerobic capacity/endurance ► Anthropometric characteristics ► Arousal, attention, cognition ► Assistive and adaptive devices ► Circulation ► Cranial and peripheral nerve integrity ► Environmental, home, work ► Ergonomics ► Gait and balance ► Integumentary integrity ► Joint integrity and mobility ► Ventilation and respiratory ► Motor function (M. control and M. learning) ► Muscle performance ► Neuromotor development ► Orthotic, protective, supportive devices ► Pain ► Posture ► Prosthetic requirements ► ROM ► Reflex integrity ► Self-care and home management ► Sensory integrity
Factors influencing the prognosis
► Age and chronicity or severity of current problem ► Multi-site or multi-system involvement ► Pre-existing systemic conditions ► Environment and support available ► Health and nutritional status ► Probability of prolonged impairments, functional limitations & disability
Examination: Systems Review
► Briefly screen/examine body systems and determine areas of intact function and dysfunction -Musculoskeletal -Neuromuscular -Cardiovascular/pulmonary -Integumentary -Communication ability, affect, language -Cognitive ability ► Areas of deficit confirm the need for further detailed examination or referral to another health professional
Factors to consider when evaluating data:
► Degree of functional loss and disability ► Patient's overall health and activity level ► Availability of social support systems ► Living environment ► Co-morbid conditions ► Extended time of involvement (chronicity) ► Medical stability, etc.
Coordination and Communication
► Effective communication with all rehab team members, directly and indirectly ► We communicate with assistants/aides ► Other professionals ► Family/S.O./Caregiver ► Provides POC recommendations to other facilities (out pt, SNF, ECF, LTAC, home health) ► Neuro clients (Rehab, SNF, etc.) more involved than typical ortho patients
What factors influence clinical reasoning?
► I. Physical therapist (goals, PT's values, PT's beliefs, psychosocial skills, knowledge base and expertise, problem-solving strategies, procedural skills) ► II. Patient/client characteristics (goals, values and beliefs, physical, psychosocial, educational, and cultural factors) ► III. Environmental factors (clinical practice environment (SNF or Rehab, weekend or weekday), overall resources, time, level of financial support, level of social support) ► IV. Experience level of clinician
Anticipated Discharge plan
► Initiated: ►Early in rehab stay ►If patient refuses further tx or is medically/psychologically unstable ►If patient is discharged before outcomes (LTGs) are reached, provide the reasons for discontinuous of services
Patient/Client-Related Instruction
► Instructions: Ensuring a successful rehabilitation and transition to home ► Communication: Based on age, cultural backgrounds, language, educational level, cognitive deficits ► Training: 1:1, group or classes, printed or AV materials ► Document what was taught, who was trained, when the training occurred, how the training was received
Patient/family Participation in Planning
► Involving the patient and the family in the planning process is essential ►Adherence to the POC ►Overall satisfaction ►Mandatory for the accrediting bodies over hospitals and rehabs ► You will fail if you take control and establish "your goals" not "their goals" (Don't assume the role of "expert") ► Goal for pt's not likely to "recover": increase ability to manage their life in the context of ongoing disability
Documentation
► It is an essential requirement for timely reimbursement ► Crucial for communication among team members ► It is "the word" if you are in a litigation ► Data included in the medical record must be: ►Meaningful ►Complete ►Accurate ►Timely ►Systematic
Examination: Patient History
► Medical record review ► Interview: (Pt, family, S.O., caregiver) should be used to establish rapport, effective communication, and mutual trust ►Past and present medical conditions/complications ►Mechanism of injury ►Prior diagnostic imaging/testing ►Medication ►Prior surgical and therapy history ►"Describe current condition and complaint" ►Patient often describes difficulties in terms of functional limitations or disabilities
Clinical decisions in neuro rehab
► Organizing and prioritizing data - Absolute MUST! -What is important and relevant to the patient and their functional mobility? ► Planning effective treatments ► ICF Model (Framework for decision making) ► Evidence-based practice! ► FUNCTION, FUNCTION, FUNCTION
Predicted level of optimal improvement
► POC should also include a statement regarding the patient's overall rehabilitation potential: Excellent, Good, Fair, or Poor - The therapist considers multiple factors when determining rehabilitation potential, such as the patient's condition and onset date, co-morbidity, mechanism of injury, and baseline data
Elements of a discharge plan
► Pt/family education ► Follow-op/referral ► HEP ► Home evaluation
Examination: Tests and Measures
► The use of disability-specific standardized instruments can facilitate the examination process but may not always be appropriate for each individual patient ► Resist the tendency to gather excessive and extraneous data in the mistaken belief that more information is better ►Unnecessary data can make clinical decision making more difficult and raise the cost of care
The prediction questions
► What is our predicted outcome? ► How much time will it take to reach that outcome? ► What are the barriers that may limit the process? ► What are the assets that may assist the process? ► What is the discharge disposition?
Evaluation
► making a clinical judgment, based on the data gathered from history, S.R. and test/measures - Prioritizes impairments, activity limitations, and participation restrictions to develop a problem list
Outcomes
►Ongoing collection from reexamination ►A determination is made whether goals and outcomes were reasonable given pt diagnosis and progress made ►If goals are achieved, do goals need to be revised or is discharge appropriate? ►If goals were not achieved, why were they not? ►Goals realistic? ►Interventions appropriate? ►Patient motivated? ►CAREFULLY DOCUMENTED The plan becomes a fluid statement of how the patient is progressing and what goals and outcomes are achievable. Its overall success depends on the therapist's ongoing clinical decisions making skills and on engaging the patient's cooperation and motivation. *goals are a way to achieve your ________________
Common Coordination impairments of Cerebellum
◦ Asthenia ◦ Asynergia ◦ Delayed Reaction Time ◦ Dysarthria ◦ Dysdiadochokinesia ◦ Dysmetria ◦ Dyssynergia ◦ Gait ataxia ◦ Hypotonia ◦ Hyper/Hypometria ◦ Nystagmus ◦ Rebound Phenomenon ◦ Tremor ◦ Intension (Kinetic) ◦ Postural (Static)
Treatment of cerebellar deficits: High intensity motor training
◦ Mixed PT and OT interventions for 12 hours a week for 4 weeks can lead to improvements in gait speed, ataxia, fall frequency and ADL
Movement strategies for Balance: Hip strategy
◦ faster sway frequencies, larger disturbance, surface is small or compliant - Primary control for mediolateral stability. Typically recruited with faster sway frequencies and larger disturbances, or when support surface is small - proximal to distal (shifts in COM by flexing/extending at hips) - forward sway: abdominals first then quadriceps - backwards sway: paraspinals then hamstrings
