Ch. 19 Pedretti (pt. 2) -- Assessment of Motor Control Flashcards
(38 cards)
1
Q
Normal postural mechanism
A
- Automatic movements/reactions that develop early in life and provide stability & mobility
- Responsible for continuous postural adjustments to movement.
- Includes normal postural tone and control, integration of primitive reflexes, mass movement patterns, righting reactions, equilibrium reactions, protective reactions and selective movement
- Disrupted when upper motor neuron system (UMNS) is damaged.
- Can cause: abnormal tone, slow and uncoordinated movements
- Therapists must assess damage to the normal postural mechanism in clients with CNS trauma or disease
2
Q
Righting reactions
A
Directs head to an upright position in space, in normal relation to trunk. W/O reaction, would have a difficult time getting out of bed, sitting up, kneeling
3
Q
Equilibrium reactions
A
Helps sustain or keep a position, first line of defense against falling, maintains or recover balance through stimulation in the inner ear
4
Q
Protective reactions
A
- Second line of defense against falling. W/O, client may be reluctant to bear weight on affected side during bilateral activities
5
Q
Assessment of Righting, Equilibrium, Protective Reactions, and Balance
A
- May be difficult to assess due to client limitations or time constraints
- Possible to assess these reactions during transfers and ADLs
- Client shifts too far beyond midline during lower body dressing
- Maintaining balance relies on normal equilibrium and protective reactions
- Assess client’s dynamic & static balance before leaving unattended on a mat table, wheelchair or during ambulatory ADLs
- The Physical Performance Test - assesses physical function during activity, includes 9 items (7 of which assess balance). Takes 10 minutes to complete (see Fig 19-5 on pg. 475)
6
Q
Primitive reflexes
A
- Include both brainstem level reflexes and spinal level reflexes
7
Q
Brainstem level reflexes: Asymmetric Tonic Neck Reflex (ATNR)
A
- Tested with client sitting or supine
- Stimulus: Move client’s head 90 degrees to one side
- Response: Fencer pose present (flexor tone of limb behind head and extensor tone of limb in front of face) - Client may have difficulty maintaining head in midline while moving eyes toward or past midline
- May be unable to move arms to midline, especially while supine
- Makes it difficult or impossible to bring object to mouth, hold an object in both hands or grasp object in front of body while looking at it
8
Q
Brainstem level reflexes: Symmetric Tonic Neck Reflex
A
- Tested with client sitting or in quadruped
a. Stimulus: Flex client’s head and bring chin to chest
b. Response: UE flex and LE extend
c. OR extend client’s head
d. Extension of UE and flexion of LE - Unable to support body weight on hands and knees
- Difficulty moving from lying to sitting
- Difficulty transferring from bed to wheelchair and vice versa
9
Q
Brainstem level reflexes: Tonic Labyrinthine Reflex (TLR)
A
- Tested with client supine and head in mid position
a. This positioning IS the stimulus
b. Response: Increase in extension tone OR extension of extremities
c. OR test while cline is prone and head in mid position
d. increase in flexor tone or flexion of extremities - Severely limited in ability to move
- Difficulty sitting up independently from supine, to rollover or sit in a wheelchair for long periods
- While attempting to sit up, extensor tone will dominate until client is halfway, then flexor tone takes over. Continues until fully sitting, causing head to fall forward, spine flexes and client falls forward
- Wheelchair can cause increased extensor tone as client tries to view environment, increasing risk of slipping out of chair
10
Q
Brainstem level reflexes: Positive Supporting Reaction
A
- Stimulus: pressure on ball of foot
a. Response: co-contraction of knee and hip joint flexors and extensors, causing rigid extension of LE
b. May also see internal rotation of hip, ankle plantar flexion and foot inversion - Difficulty standing
- Difficulty placing heels first while walking & normal body weight transference
- Impossible to move joints while weight bearing making getting up from chair or walking down stairs difficult
- Balance reactions compensated by other body parts
11
Q
Spinal Level Reflexes
A
- Can occur after UMN lesion
- Reflexes rarely occur in isolation
12
Q
Spinal level reflexes: Crossed Extension Reflex
A
- Increased extensor tone in one leg while other is flexed
- Normal walking pattern may be affected. In client with hemiplegia w/this reflex, if they flex their unaffected leg to walk, a strong hypertonicity occurs in in affected leg
13
Q
Spinal level reflexes: Flexor withdrawal
A
- Stimulus: sole of foot is touched, swiped from heel to ball of foot
- Response: flexion of hip, knee, ankle
- Interferes with gait and transfers
14
Q
Spinal level reflexes: Grasp Reflex
A
Client will be unable to release an object, even when active finger extension is present
15
Q
Trunk control assessment
A
- A valid assessment for clients with a CVA
- Involves four timed tests: rolling to the weak side, rolling to unaffected side, moving from supine to sit, sitting on side of bed w/feet off floor for 30 seconds
- Must evaluate strength & control in trunk flexors, extensors, lateral flexors and rotators
- Client should sit upright on mat table with feet supported
- Do not leave client unattended until trunk control has been assessed
16
Q
Trunk flexor assessment
A
- Client sits upright and then slowly moves shoulders behind hips (eccentric), then hold end-range posture (isometric), then asked to slowly return to starting position (concentric)
- Observe for unilateral weakness, fall risk, symmetry of weight shift
- Functional testing could be observing client move from supine to sit
17
Q
Trunk extensor assessment
A
Test 1 - assesses concentric trunk extensor control, needed for LE dressing and forward reach
- Sit with spinal flexion, posterior pelvic tilt
- Move into trunk extension while also moving pelvis into neutral or slight anterior tilt
Test 2 - evaluates eccentric trunk extensor control
- Seated in upright posture
- Ask client to maintain erect spine and lean forward
- Observe unilateral weakness and note end-range control
Test 3 - trunk extensors contract concentrically
- Ask clients to move shoulder back to a seated, aligned & upright position
18
Q
Lateral flexor assessment
A
- Client sits in upright position with stationary pelvis and upper trunk laterally flexed toward mat table then returns to starting position
- Lateral flexion needed for fall prevention when reaching to side
19
Q
Trunk rotation assessment
A
- Primary muscles are obliques
- Prerequisite for UE dressing and reaching across midline
- Three movement patterns evaluated:
1. Client sits upright with neutral, stable pelvis. Client reaches across body in direction of floor. Repeat other side.
a. Assesses concentric control of obliques and back extensors
2. Upper trunk remains stable, lower trunk and pelvis move forward on one side. Repeat other side
a. Assesses trunk extension with rotation
3. Client in supine and initiates a segmented roll, lifting shoulders from surface and moving toward opposite side.
a. Assesses concentric contraction of obliques
20
Q
Coordination
A
- Characteristics include: smoothness, rhythm, appropriate speed, refinement to minimum number of muscle groups needed, appropriate muscle tension, postural tone and equilibrium
- Controlled by cerebellum, influenced by extrapyramidal system
- All elements of neuromuscular system must be intact
- Requires intact proprioception, body scheme, ability to judge space accurately, correct timing
- Depends on contraction of correct agonist muscle and relaxation of correct antagonist
21
Q
Incoordination
A
- Non cerebellar causes include diseases and injuries of muscles and peripheral nerves, lesions of posterior column of spinal cord, lesions in frontal or post-central cerebral cortex
- Paralysis of limbs caused by PNS lesion, prevents testing for coordination
- Includes both cerebellar disorders and extrapyramidal disorders
22
Q
Incoordination: Cerebellar Disorders
A
- Can cause incoordination that can affect any body region
- Postural difficulties i.e slouching or leaning, spinal curvature
- Common signs include ataxia, adiadochokinesis, dysmetria, dyssynergia, rebound phenomenon of holmes, nystagmus, dysarthria
23
Q
Ataxia
A
- Is the delayed initiation of movement responses, errors in range and force of movement , errors in rate and regularity of movement
- Poor coordination between agonist/antagonist muscle groups
- Jerky, poorly controlled movements
- Gait ataxia → swaggering, wide-based with little or no arm swing, uneven step length and may have tendency to fall
- Poor postural stability
24
Q
Adiadochokinesis
A
- The inability to perform rapid alternating movements (such as pronation and supination)
- Can test by how many cycles a client can perform in 10 secs
- Test unaffected side first
25
Dysmetria
- The inability to estimate the ROM necessary to reach target of movement
- Hypermetria - limb overshooting
- Hypometria - limb undershooting
26
Dyssynergia
- Voluntary movements broken into component parts and appear jerky
- Can also cause problems in articulation
27
Rebound Phenomenon of Holmes
- Inability to stop a motion quickly to avoid striking something
- Example: client’s arm flexed against resistance by examiner and then the resistance is suddenly released, client’s hand will hit their face/body
28
Nystagmus
- Involuntary movement of eyeballs up and down, back and forth or rotating direction
- Interferes with head control and fine adjustments for balance
29
Dysarthria
Explosive or slurred speech from incoordination of speech mechanism. May also vary in pitch, seem nasally
30
Extrapyramidal Disorders
- Characterized by hypokinesia or hyperkinesia
- Parkinson’s displays hypokinesia, cogwheel and lead pipe rigidity, decrease or loss of postural mechanisms, resting pill rolling tremor
- “Parkinson’s Plus” - group of movement disorders that have signs of parkinson’s with concomitant neurologic deficits
a. Seen in Progressive Supranuclear Palsy, has a shorter life expectancy than Parkinson’s
- Include chorea, athetoid movements, dystonia, ballism, tremor (3 types)
31
Chorea
- Is defined as irregular, purposeless, involuntary, coarse, quick, jerky and dysrhythmic movements
- Occur during sleep
- Seen in tardive dyskinesia and Huntington’s disease
- Patients with Huntington’s have ataxic gait as well as choreo-athetoid movements
- Choreiform movements faster than athetoid movements
32
Athetoid movements
- Are continuous, slow, wormlike, arrhythmic movements that primarily affect distal portions of extremities
- Occur in same patterns, not present during sleep
- Adult athetosis can occur after cerebral anoxia and Wilson’s disease
- Alternating extension and flexion of arm, supination/pronation, flexion and extension of fingers
- Athetosis with chorea → Choreoathetosis
33
Dystonia
- Is the persistent posturing of the extremities (e.g. hyperextension or hyperflexion of the wrist and fingers) often with concurrent torsion of the spine and twisting of the trunk
- Often continuous and in conjunction with spasticity
- Dystonia can be primary or secondary (with other CNS disorders)
- Segmental dystonia involves 2 or more adjacent body parts
- Generalized and focal dystonia
a. Focal dystonia involves one limb as seen in writer’s cramp
34
Ballism
- Rare symptom produced by abrupt contractions of axial and proximal musculature of extremity
- Cause limb to fly out suddenly
- Hemiballism → one side of body
35
3 Types of Tremor
Intention tremor, resting tremor, essential familial tremor
36
Intention Tremor
- Associated with cerebellar disease
- Occurs during voluntary movement
- Intensified at termination of movement
- Often seen in multiple sclerosis
37
Resting Tremor
- Occurs at rest and subsides w/voluntary movement
- Occurs as result of damage to basal ganglia
- Seen in parkinson’s
38
Essential Familial Tremor
- Inherited as autosomal dominant trait
| - Most visible when client carries out a fine precision task
