dysmetria
a lack of coordination of movement typified by the undershoot or overshoot of intended position with the hand, arm, leg or eye
choriform
involuntary, rapid, irregular jerky movements
apraxia
inability to carry put purposeful movement in presence of intact sensation, movement and coordination - aka motor planning difficulties
dysdiadochokinesia
the impaired ability to perform rapid, alternating movements
athetosis
slow, involuntary writhing and twisting (usually face and arms)
dystonia
sustained muscle contractions causing twisting, repetitive movements, and abnormal postures - basal ganglia
somatagnosia
lack of awareness of body structure and relationship of body parts to one another
associated movements
unintended movements of one limb during contractions of another limb - often seen in spastic patients
anosognosia
denial of presence or severity of one's paralysis
ashworth scale
0 = no increased tone
1 = slight increase (min resistance at end range)
1+ = resit less than 1/2 the range
2 = increase tone thru range (still moves easily)
3 = considerable tone (PROM difficult)
4 = rigid in flexion or extension
tardieu
0 = no resistance through PROM
1 = slight resit (no clear catch)
2 = clear catch at precise angle
3 = fatiguable clonus < 10 sec
4 = unfatigable clonus > 10 sec
5 = immovable joint
what is the cut off score for tinetti
< 19 = fall risk
what is the cut off score for berg
<46 = fall risk
what 5 tests assess fall risk
tinetti, berg, TUG, functional reach, multidirectional reach
performance
ability in current environments
capacity
ability in standard/uniform environment
health condition (pathology)
cellular level - interruption of the body's normal process
examples: CVA, TBI, MS, Parkinson's, SCI, LMN
body structure/function (impairments)
organ/system disorders - loss or abnormality of physiological or psychological structure or function
both primary and secondary impairments
examples: tone, cognition, behavior, coma
activity limitation (functional limitations)
whole body function - restriction of ability to performa physical activity, action or task in an efficient, typically expected, competent manner
examples: walking, transfer, stairs, ADLs
participation restrictions (disabilities)
inability to engage in expected, age-appropriate roles or tasks in a particular social context and physical environment
examples: unable to play with kids, grandkids
societal limitation
unique aspect of NCMRR - restrictions attributable to social policies or barriers that limit individuals' abilities to fulfill their expected roles
external factors
availability of health care, school services, finances, physical support, social support
internal factors
lifestyle and behaviors, self-efficacy, faith, adaptability to change
motor control
ability to regulate or direct mechanisms essential to movement
movement results from interactions between:
individual, task and environment
individual contraints:
physiological systems
perception/sensation
cognition
task constraints:
-functional categories
-critical neural control mechanisms
-task requirements
-task movement variability
theory of motor control
group of abstract ideas about
the control of movement
reflex theory
sensory input controls motor output via reflexes
- reflexes are building blocks of complex movement and behavior
limitations to reflex theory
1. does not explain spontaneous behavior and feedforward control
2. movement can occur without sensory input
3. does not explain rapid sequences of movement (typing)
4. single stimulus can result in varying responses depending on context and descending co
hierarchical theory
central programs control muscle activation pattern in a top down organization. aka brainstem controls SC, cortex controls brainstem
- developmentally based
- separation of voluntary and reflex movements
hierarchical theory limitations
- control is both parallel and hierarchical
- does not explain reflex behavior in adults
- does not consider effects of other systems
systems model theory
body is a mechanical system subject to internal and external forces
- we control movement by controlling degrees of freedom
systems theory limitations
- more emphasis on biomechanics
- many variants of theory
neurologic rehabilitation techniques
- muscle re-education
- facilitation
- task oriented
muscle re-education model theory
Nervous systems goal in motor control is to activate individual muscles and motor units
neurotherapeutic facilitation theory
based on reflex and hierarchical models of motor control
- reflexes
- developmental
- recovery occurs same pattern as development
task-oriented model theory
based on systems model of motor control
- targets both peripheral and central systems
- movement control is organized around goal-oriented, functional behaviors rather than muscles or movement patterns
PNF
active muscle contractions causes proprioceptive information to be sent to the CNS, which increases excitation and excitement of additional motor units
By what pathway does proprioceptive info travel to the CNS
DCML
Brunnstrom
movement synergies occur at the spinal cord level as a result of CNS hierarchical organization - specific recovery sequence
brunnstrom stages of recovery
1. flaccid
2. weak synergy
3. strong synergy
4. some deviation from synergy
5. relative independence from synergy
6. recovery
homolateral sykinesis
resisted flexion of the upper extremity causes induced flexion of LE
ramniste's phenomenon
resistance of abduction or adduction produces similar reaction in affected limb
NDT
abnormal movement and postural patterns result from loss of CNS control and release of abnormal reflexes that inhibit righting and equilibrium reactions
- focus on postural control and coordination of muscle function
which facilitation technique uses "handling techniques via key points of control
NDT
Rood theory
motor function is inseparable from sensory function
- activate movement and postural responses in an automatic way
7 stages of ontogenetic sequence of movement
1. lying supine
2. rolling
3. prone pivot
4. prone on elbows
5. quadruped
6. standing
7. walking
4 stages of treatment to obtain controlled movement - ROOD
1. total movement patterns elicited (mobility)
2. gain postural stability (stability)
3. weight shifting (controlled mobility)
4. free movement (skill)
motor learning programme
based on redundancy theory, denervation supersenstivity, neural sprouting, behavioral strategy change
- motor control is key concept and central to every aspect of motor performance
performance
temporary change in motor behavior seen during practice sessions
learning
relatively permanent change in motor behavior or ability to complete a skilled movement
explicit
conscious recall, declarative, requires awareness, attention, reflecion
implicit
doesn't require conscious recall or higher cognitive process - frequent repetition for formation - non-associative learning, associative, procedural
intrinsic feedback
received from sensory receptors as a direct result of performing the movement
extrinsic feedback
feedback from an external source
knowledge of performance
knowledge of quality, pattern or efficiency of movement pattern produced
knowledge of results
concerned with extent to which a goal was achieved - enhances motor learning skills
concurrent feedback
feedback given during a movement
terminal feedback
feedback given at the end of movement
immediate feedback
improve performance during acquisition phase
summary feedback
improves performance in retention phase
faded schedule
as patient gets better at doing a task, giving them less and less feedback
cognitive phase
learner is new to the task
associative phase
knows the task, adjusting the subtleties
autonomous
automatic, can perform a secondary task
massed practice
practice time > rest time
distributed practice
rest time > or equal to practice time
random practice
more realistic, switching between practicing different tasks
blocked practice
better early on while learning a task
what types of activities are best for mental practice?
sequencing tasks
importance of a PT diagnosis:
links impairments and functional limitations
when does discharge planning begin?
the day of the evaluation
which gives better functional overview: functional skills testing vs impairment testing?
functional skills
what are the levels of the ICF?
- body function
- activity limitations
- participation
what are the core outcome measures to be performed on every neurological patient if possible?
- berg
-FGA
- ABC
- 10 meter walk test
- 6 minute walk test
quantitative movement analysis includes what 3 main categories?
- safety (both short term and long term)
- efficiency
- effectiveness
what are potential impairments?
- perceptual skills - cognition
- cranial nerve function
- respiratory function
- strength
- sensation
- skin integrity
- motor control and coordination
- ROM
- tone
- balance and postural control
what do you do if the patient does not have enough selective control to MMT?
document what the patient is able to do and what compensations they may use for that task to then be able to compare later on what they do now
what are the assumptions if you assign a MMT grade?
that a person has full AROM of that motion
you are able to check AROM with what testing?
strength testing
you are able to check PROM with what testing?
Tone testing
tone
velocity dependent resistance to passive ROM
- assess at varying speeds to determine if it is spasticity, soft tissue v joint restriction, fixing degrees of freedom
tardieu scale - velocity
V1: as slow as possible, slower than the natural drop of the limb segment under gravity
V2: speed of limb segment falling under gravity
V3: as fast as possible, faster than the rate of the natural drop of the limb segment under gravity
MSR
0 = absent
1+ = trace
2+ = normal
3 + = brisk
4+ = non sustained clonus
5+ = sustained clonus
tips for examination
- use pt diagnosis to prioritize suspected impairments
- minimize position changes
- don't continue to test if its normal
- be efficient
short term goals look at:
- changes in impairments
-small steps toward functional LTG
- changes in movement strategy or quality
- patient/family education
- address equipment and/or environmental barriers
long term goals look at:
-observable, measurable (SMART)
-functional
-meaningful to the patient
what are the overall motor deficits affecting a person with CNS disorders
- weakness
- changes in tone
- coordination problems
- involuntary movement
- secondary musculoskeletal impairments
paralysis or "plegia
total or severe loss
paresis
partial loss of muscle activity
treatment of persons with flaccidity, hypotonia or extreme weakness includes:
- task-oriented activities (rolling, sit to stand)
- improve sensory awareness: sensory stimulation
- facilitation techniques
- WB sequence (WB to nonWB)
treatment of persons with volitional isolated contraction includes:
-strength training
-task oriented activities
-forced use
-upright balance activities
-other types of ther ex.
does strengthening increase spasticity?
NO
true or false: CVA patients and TBI patients can probably tolerate exercise at a greater intensity than they commonly get in PT sessions
TRUE
other types of therapeutic exercieses
PNF, AAE, AROM, PRE, Isokinetic training, electrical stimulation, biofeedback, pilates, therapeutic balls, endurance activities
tone
resistance to passive stretch
hypertonia
increased resistance to passive stretch
spasticity
velocity dependent increased resistance to PS in one direction
rigidity
non-velocity dependent increased resistance to to PS in both directions
opisthotonos
total body extension, arching of back so only head and heels are touching the mat - whole body extension
what are non-neural components to tone?
- elasticity/stiffness of the muscle
-muscle shortening begins to happen almost immediately after stroke
what are neural components to tone?
- changes in the input onto the alpha motor neurons
what are other contributors to tone and "abnormal movement patterns"?
- weakness
- loss of selective control and coordination
why do we treat spasticity?
- improve function
- reduce pain
- improve care
- prevent secondary impairments (contractures)
- increase ROM
is spasticity the cause of the movement dysfunction?
or is it ROM, active movement, spasticity, or all of them due to them having effect on each other
true or false: strengthen both antagonist and agonist muscles in a spastic patient
true
what are inhibition techniques to reduce spasticity?
- slow, prolonged stretching, weight bearing, prolonged ice, inhibitory pressure on tendons, slow vibration over muscle belly, rotation, facilitation and strengthening of antagonist
what can positioning in correct alignment help?
- brain stem reflexes, serial casting, dynamic splints, tone reducing orthotics and splints
what is a major medication that is often used in spastic patients
baclofen, also a baclofen pump but must pass the oral trial first
what does botulism toxin do?
blocks ACH release at NMJ, then follow up with strengthening and motor control
baclofen pump qualifications:
- pump inserted into abdomen
GABA agonist at receptors in SC
requires PT, candidates selected by:
- minimum size requirement
- must tolerate baclofen, and baclofen must be effective in oral trial
- must be compliant with follow up visits
what is a dorsal root rhizotomy?
-approximately 70-90% of dorsal rootlets are cut
-used mainly in kids with spastic diplegia
-very effective at reducing spasticity but there is significant residual weakness
who is a candidate for DRR
- must be compliant and cooperate with extensive PT after surgery
- must be cognitively in tact
-size/age requirements
-considerable pre-testing and post-testing required
coordination
activation of multiple joints and muscles at the appropriate time and with correct amount of force resulting in smooth, efficient, accurate movement
what could issues at the cerebellum present as?
movement decomposition, dysmetria, hypotonia, asthenia, disdiadochokinesia, tremor, speech and eye movement problems, posture and gait deficits
what could issues at the basal ganglia present as?
-hypokinesia, bradykinesia, rigidity, tremor, akinesia
-chorea, athetosis, hemiballismus, dystonia
-dyaphagia, dysarthria, respiratory compromise
what could issues at the dorsal columns present as?
spinocerebellar tracts: proprioceptive loss, WBOS, gait dysmetria, balance and equilibrium disturbances, slowing of voluntary movement
what could issues with CNS lesions present as?
-lesions that result in weakness, abnormal tone, and/or muscle imbalance
- lesions of the SMA and PreMC result in poor coordination and poor motor coordination
what are the 3 major types of coordination problems?
- activation and sequencing problems
- timing problems
- difficulty scaling forces
activation and sequencing problems present as:
-abnormal synergies - stereotyped movement patterns that can't be adapted to task or environmental demands
-abnormal coactivation (co-contraction)
-impaired interjoint coordination
timing problems present at:
- difficulty initiating movement
- slow movement
- difficulty terminating movement
what does assessing incoordination look like?
- careful observation of movement
- non-equilibrium tests
-standardized hand and arm function tests
-tests involving equilibrium
what does treating incoordination look like?
- try to isolate the type of coordination deficit
-repetition and practice, gradually increasing demands
-provide visual feedback with gradual withdrawal
-increase proprioceptive input
- WB activities
- improve postural control
- coordination exercises
how to treat incoordination timing problems
- practice functional tasks under time constraints
-ideas to decrease rigidity and hypokinesia
- grading force
which speed demands less accuracy: fast or slow
fast, slow the task down to see how a person performs it truly
which type of task requires high accuracy?
functional tasks
tremor
rhythmical, involuntary movement
associated movements hypothesis
- loss of supraspinal inhibitory mechanisms that normally suppress the coupling of intralimb and interlimb movements
how to assess involuntary movement
- describe the movements
- describe condition under which they are activated
how to treat involuntary movement
- compensation
- maximize postural control and trunk control
- WB and approximation
-distal fixation
- limb weighting (controversial)
examples of secondary musculoskeletal impairments
- loss of ROM and contractures
-joint malalignment
-subluxations and dislocations
-osteoporosis/fractures
sensory impairments could be:
-somatosensory loss
- visual loss
-vestibular problems
cognitive/perceptual impairments
- perceptual changes
-apraxia - motor planning
- cognitive impairments
what are other cognitive impairments?
- attention
-orientation
-memory
-problem solving
-arousal and level of consciousness
focused attention
can they focus in on the task you are asking of them to do
sustained attention
how long can they stay focused on the task
selective attention
able to selectively attend to one thing
alternating attention
able to go between two different tasks
divided attention
performing dual tasks
neuroplasticity
-adaptive capacity of the CNS to modify its own organization and function
-ability of neurons in the brain to respond to changes in their environment
when does neuroplasticity occur?
- normal development
- during learning and/or practice throughout our lifetime
- as a result of lesion/infarct - adaptive or maladaptive
plasticity continuum
- ST changes in synapse efficiency and strength
- LT changes in organization and number of synapses
learning continuum
ST to LT changes in ability to produce skilled action
what area of the brain did they find had growth in taxi drivers?
- hippocampal growth related to visuospatial memory of map
primary damage to CNS:
- direct damage to neurons
- cytotoxic edema - cellular level
- vasogenic edema - blood level
- edema compresses axons and blocks conduction
secondary damage to CNS:
- altered blood flow to an area (focal ischemia)
- change CSF or cerebral metabolism
- tissue hypoxia/lactate accumulation causes acidosis, glutamate accumulation, release of free radicals
effects of damage on neuronal function
- neuron death
- interrupt axonal projections (DAI)
- cascading degeneration
cascading degeneration
denervation of populations of neurons innervated by injured neurons
- one isn't getting sent so then further down the line another one isn't getting the signal and so fort
spontaneous recovery
effort to limit the severity of the initial injury to minimize loss of function
intervention/training
efforts to reorganize the brain to restore and compensate for function that has already been compromised or lost
CNS response to injury
- resolution of neural shock
- synaptic hypereffectiveness
- denervation supersensitivty
- recruitment of silent synapses (unmasking)
- sprouting/synaptogenesis
resolution of diaschisis
recovering of synaptic effectiveness due to lessening of edema and reabsorption of blood in hemorrhage
synaptic hypereffectiveness
- increased release of neurotransmitter from remaining synaptic sites
denervation supersensitivity
- re-establishment of pre-morbid neurotransmitter levels
- changes in postsynaptic membrane that make the neuron more sensitive to NT released by remaining inputs
recruitment of silent synapses (unmasking)
-previously inactive connections become active after injury
functional substituion
functions attributed to the damaged portion of the NS taken over by areas not previously concerned with that function
- can be assumed by contralateral hemisphere or uninjured areas of ipsilateral hemisphere
true or false: every person has identical somatotopic maps
false; all different based on individuals past experiences
- environment can influence this
- unique motor skills practiced can also influence it
true or false: sensory and motor maps constantly change depending on the amount of activation by peripheral input
true; use dependent competition for synaptic connections
- neighboring areas of brain can take over if an area becomes inactive
true or false: time matters when it comes to an injury
true - more effective soon after injury, recovery may be worse if it begins TOO soon
what is the window of spontaneous recovery for a TBI
around 1 year
what is the window of spontaneous recovery for a CVA
around 6 months
which cortex has best potential for plasticity
- motor cortex, redundancy in system
which cortex may be the most susceptible to damage
prefrontal - damage not evident immediately, growing into a lesion - executive functions post TBI
what is the kennard principle?
reduced neuroplastic responses in aged brains
transference
ability of plasticity within one set of neural circuits to promote plasticity
- rTMS
- direct electrical stimulation of the motor cortex when coupled with rehabilitative training after ischemic insult enhanced motor recovery
interference
-ability of plasticity within a given neural circuitry to impede the induction of new, or expression of existing, plasticity within that same circuitry
CIMT
-aims to promote recovery and prevent compensation by constraining the unaffected limb
- behavioral experience shapes the brain which can be maladaptive (compensation) or functionally adaptive (recovery)
behavioral compensation
- response to damage and behavioral attempts to compensate for effects of damage
functional recovery
response to behavioral experience that enhances functional outcome and promotes functional reorganization
CIMT requirements
- active wrist extension (20 degrees)
- finger extension (10 degrees)
- must be able to move their arm
why does learned non-use occur?
- we cannot use limb immediately after injury (neuronal shock)
- limb use is suppressed even after shock wears off
What are the two main functions of the UE
- weight bearing
- reaching and manipulation
what are the components of UE skills?
- visual regard
- reaching (and grasping)
- grasping
- release
- in-hand manipulation
what is involved with visual regard?
-locating a target (eye-head coordination)
-locating objects in peripheral visual field
- sequential activation of eye, head and hand movements
- types of eye movements
-control of eye movements
Does the eye or the head stop moving first when focusing on an object?
eye reaches and focuses before head stops moving
Between the eye, head and arm which moves more rapidly?
the eyes due to inertia
tasks that require eye movement alone?
objects are near the periphery
tasks that require eye and head movements?
in the periphery
tasks that require eye-head-trunk movements?
in far periphery
accommodation
adjusting lens for distance
convergence/divergence
mechanism for maintaining single vision and depth perception
pursuits
smooth, coordinated, track slowly moving objects
saccades
scan rapidly between objects
Visual regard clinical steps
- practice locating targets first (central to peripheral)
- practice movements involving eye - head - trunk
- crossing midline will be more challenging so start ipsilateral and then work to cross midline
reaching (transport)
-when the arm is used to point to an object all segments of the arm are controlled as a unit
- when the arm is used to reach for and grasp an object, hand is controlled independently
arm =
transport
hand =
grasp
true or false: there are two separate pathways followed for a person to accomplish transport vs grasp
true - patients can have difficulty with either one, or both of them
grasp
the hand must adapt to the shape, size and use of the object
types of grasp:
- power grips (force transmitted to object)
- prehension grip (force directed between thumb and fingers)
types of power grips:
- hook grasp
- spherical grasp
- cylindrical grasp
types of prehension grip
- pad to pad (inferior pincer)
- tip to tip (superior pincer)
- pad to side (lateral prehension
when does grip formation take place?
during transport phase - anticipatory characteristic of object to be grasped
what are intrinsic properties of grasp
-object size, shape texture
what are extrinsic properties of grasp
- object's orientation, distance from body, location with respect from body
true or false: transport and control are controlled independently?
true - but they occur synchronously
what does timing of maximal grip size correspond with?
the beginning of arm acceleration
what are some grasp treatment implications?
- practice reaching toward targeted object in different locations without grasping it
-practice grasping and releasing different objects
-practice reaching within the context of many functional tasks
what is the order of progression for release?
- with arm support
- without arm support
- controlled dropping of object
- controlled release of object
- throwing
in-hand manipulation types:
shift, translation, rotation
shift
adjusting position of object near IP joints with thumb opposed
translation
moving between fingers and palm
rotation
turning object, stabilizing it, then moving it