L7: Methods of Eliciting Movement Recovery in the Neurological Patient Flashcards
1
Q
What are 10 Methods of Enhancing via Eliciting Movement Recovery in a neurological patient?
A
- Handling and Choice of training position
- Augmented Feedback
- Mental Practice
- Constraint‐Induced Therapy
- Electrical Stimulation
- Progressive Resistance
- Strength Training
- Treadmill Training
- Destabilising surfaces
- Emerging Technologies
2
Q
What is enhancing with handling?
A
3
Q
What are 3 things that handling techniques (provide control where joints are unstable due to weakness or sensory loss) that can be used for in a neurological patient?
A
provide control where joints are unstable due to weakness or sensory loss
- elicit selective activation of muscles
- add missing components thus reducing compensations
- guide normal performance of movements
4
Q
What are 3 things that handling techniques (provide sensory input) that can be used for in a neurological patient?
A
- primary sensory loss
- sensory inattention
- reduce overactivity or abnormal movements
5
Q
What is training position for Enhancing Position and environment and Considerations with handling with a neurological patient?
A
Training should be as functional as possible
6
Q
What are 4 characteristics of Base of Support for Enhancing Position and environment and Considerations with handling with a neurological patient?
A
- The supporting surface
- The body part in contact with it
- The relationship of the whole body and the supporting surface
- Acts as a reference point for movement
7
Q
What are 2 characteristics of the Acceptance of Base of Support (handling considerations) for a neurological patient?
A
- Ability to adjust appropriately to the contours of the supporting surface
- Ability to accept a base of support
- eccentrically lengthen muscle
- produce activity in relation to the base of support
8
Q
What are 2 characteristics of the size of the Base of Support (handling considerations) for a neurological patient?
A
- smaller BOS raises muscle activity
- larger BOS reduces muscle activity
9
Q
What are 2 characteristics of the nature of the Base of Support influencing muscle activity (handling considerations) for a neurological patient?
A
- hard unyielding surfaces raise muscle activity
- soft, yielding surfaces reduce muscle activity
10
Q
What are 2 characteristics of the bias towards automatic or voluntary movement (handling considerations) for a neurological patient?
A
- Consider normal performance of the task
- Handling can be used to encourage more automatic performance of functional tasks
11
Q
What are 2 characteristics of the speed of movement- balance with effect o muscle activity (handling considerations) for a neurological patient?
A
- Performing functional tasks at extremely slow speeds is effortful and novel
- Generally handle to encourage movement at as close to normal speed as safe and appropriate – maintain quality of mvt
12
Q
What are 2 key points of control (handling considerations) for a neurological patient?
A
- Areas of the body from which movement can be most effectively controlled
- Choice depends on the individual’s response to facilitation of movement
13
Q
What are 3 proximal key points of control (handling considerations) for a neurological patient?
A
- trunk (central key point)
- pelvis
- shoulder girdle
14
Q
What are 2 distal key points of control (handling considerations) for a neurological patient?
A
- hands
- feet
15
Q
The training environment can be structured to facilitate _____ recovery
A
movement
16
Q
What are 4 features of structuring the training environment in a neurological patient?
A
- to assist with orientation to upright
- to provide movement cues
- to make tasks easier to practice
- Help to replace an essential component (augment feedback)
- to enable safe independent practice
- Forced –> ties up unaffected side (eg. arm) and also challenge (eg. reach out of BOS)
17
Q
_____ is considered an important variable in motor skill learning
A
Feedback
18
Q
What are 2 types of performance related feedback?
A
- Task‐intrinsic feedback
- the sensory‐perceptual information that is a natural part of performing a skill
- ‘Ideally where you want them to leave with intrinsic feedback
- Augmented feedback (extrinsic feedback)
- adding to or enhancing task‐intrinsic feedback with an external source
- Sense of where you are
19
Q
What are 4 characteristics of augmented feedback?
A
- The role of the therapist is to provide feedback that is likely to assist learning in the most effective way
- Feedback should be used in a focused and deliberate way
- Tailored to the client’s mix of impairments
- Guided by evidence where available
- Intrinsic feedback mechanisms must be used for efficient performance of functional tasks. Therefore during task practice
- Must gradually withdraw various forms of extrinsic feedback
20
Q
What are 7 types of augmented sensory feedback used during task practice?
A
- Visual
- Auditory
- Kinematic
- EMG
- Somatosensory (Tactile and Proprioceptive)
- Thermal
- Vestibular
21
Q
What are 2 types of videos for visual feedback?
A
- Real‐time
- Playback analysis with client
22
Q
How can you progress attention for visual feedback?
A
Progress attention
- from task being practised
- to the functioning environment
23
Q
What are 3 progressions in the manipulation of the amount of visual feedback?
A
- From bright to dim environments
- From visually simple to challenging environments
- Progress to balance retraining without vision if appropriate
24
Q
What is visual scanning for visual feedback?
A
Train scanning for attention to body and visual field
25
What does Visual Restoration Therapy look like (visual feedback)?
26
What is visual feedback about?
Visual feedback about weight distribution and weight shift activity
27
What is mirrow therapy for visual feedback?
Move non-paretic arm while looking in a mirror that gives the impression that the paretic limb is moving
28
What are 5 features that have no significant treatment effects when it comes to visual feedback devices?
1. symmetry of weight distribution
2. postural sway
3. balance control
4. walking ability
5. gait speed
29
What are 4 characteristics of auditory feedback during task training?
1. verbal cuing as appropriate for:
* age
* receptive level
* dyspraxias
* level of consciousness
2. use of volume for alertness and activation (voice/music)
3. use of soft environmental sound (music) for relaxation of increased tone
4. Development of co‐ordination, rhythm and timing:
* music
* voice
* metronome
30
What are the 3 parameters of gait for EAR (external auditory rhythms) to see improvement of stride length and comfortable gait speed?
1. Time post stroke 16 days ‐ 32 months
2. 20 ‐ 30 min/day
3. 2 – 10 times a week for 3 ‐ 12 weeks
31
What are 4 characteristics of Portable weight distribution auditory feedback devices (for Auditory Feedback of force production or weight‐bearing)?
1. Limited research
2. Limb load monitor:
3. load sensing pads
* buttocks
* whole foot
* forefoot
* Heel
4. audio signal can be set to go on or off with load bearing or joint in particular range
32
What are 3 characteristics of joint angle biofeedback for kinematic feedback? Is it beneficial?
1. appears beneficial
2. improves ability to position joints and body segments targeted
3. transition into functional improvement not clear
33
What are the 2 benefits of using Wii Fit/ Xbox-Kinect?
1. Improves engagement
2. Positive outcome for balance restoration
34
What is EMG biofeedback?
* Instrumentation applied to the patient’s muscles with external electrodes to capture motor unit electrical potentials
* The biofeedback unit converts the potentials into visual or auditory information for the patient and therapist
35
What is 2 things that the EMG biofeedback training method involves?
1. Augmenting desired muscle action
2. Decreasing unwanted muscle activity
36
What are the 3 benefits of EMG biofeedback?
1. Allows independent practice
2. Particularly useful for patients with sensory loss, aphasia, attentional deficits
3. Provides feedback when muscle activity is not sufficient to cause joint angular change
37
What is the evidence for EMG-BFB on the recovery after stroke?
1. EMG-BFB has an uncertain impact on recovery after stroke
2. Small evidence from individual studies to suggest that EMG-BFB plus standard physiotherapy produces improvements in motor power, functional recovery and gait quality when compared to standard physiotherapy alone
3. Combination did not find a treatment benefit
38
Plasticity of the sensory cortex can be induced with\_\_\_\_\_\_
training
39
\_\_\_\_\_\_ can expand sensory areas of the cortex
Sensory stimulation
* Type and duration of stimulation required
40
What are 6 components of somatosensory retraining?
1. Tactile localisation
2. Two point discrimination
3. Sharp/blunt discrimination
4. Texture discrimination
5. Object recognition
6. Joint position copy
41
What are 4 characteristics of weight bearing for its simulation for Proprioceptive Input and Feedback?
1. Compression
* Activate muscles (extensors)
2. Approximation
3. Weights
4. Tilt table
42
What is handling for proprioceptive input and feedback?
sweep tapping or tapping specific muscles to increase attention and elicit specific muscle activation via quick stretch
43
What are 4 ways you increase proprioceptive feedback via application?
1. Taping (for activation)= Putting joint in optimal position for activation
* Posterior knee for hyperextension
* Gluteal
* Shoulder girdle/glenohumeral joint
2. Compressive bandaging
3. Orthoses
4. Tone and Positioning (TAP) splints
44
What are 3 characteristics of Facilitatory Stretch for Proprioceptive Input and Feedback?
1. quick stretch (Execution and timing)
2. sweep tapping of specific muscles
3. tapping to guide selective movements
Can practice independently
Altered proprioceptive input
* e.g. varying floor surface
45
What are 2 characteristics of vibration for Proprioceptive Input and Feedback?
1. light, fast applications for activation of specific muscle groups
2. Whole body vibration devices
Predominately used to activate core muscles of people with back pain
46
What are 2 purposes of vestibular input for Positioning for rest and treatment?
1. minimise soft tissue shortening
2. minimise influence of increased tone
47
What are 5 characteristics of vestibular input?
1. Rocking and swaying in supported positions for relaxation
2. Normal movement activates vestibular system in functional context
3. Ensure movement through all planes
4. Displacement to facilitate postural reactions
* self displacement
* external displacement
5. Displacement to facilitate awareness of self and movement
Most basic strokes - inner ear not affected, but usually deteriorate with age
48
What are 2 characteristics of Vestibular ocular integration?
1. Gaze stability and head / eye follow exercises
* Can have convergence and divergence problems
2. Integration of vestibular ocular reflex
* Look, turn and apply motor output
Can manipulate environment to change difficulty of task (eg. balloon is slower)
49
What are 3 characteristics of Enhancing or replacing via Mental Practice?
1. In athletes
* Mental practice combined with physical practice:
* promotes the learning of motor skills
* maintains the level of performance of athletes when physical practice is not possible
2. More recently investigators have proposed the use of mental practice in neurological rehabilitation
3. Potentially cost‐efficient means of promoting motor recovery after cerebral lesions
Must be imagined doing an actual task (eg. reach to a particular object rather than just reach hand up)
Activates the brain and reduces the brain decay
50
What are 3 features that mental practice consists of?
1. repeating an imagined movement, through motor imagery
2. several times
3. with the intention of improving motor performance
51
What are the 3 characteristics of mental practice?
* The processes underlying motor imagery are similar to those active during actual movement
* The neural network involved in motor imagery and motor execution overlap
* primarily in the premotor and parietal areas, basal ganglia, and cerebellum
52
What are 3 benefits of mental practice?
1. increase use of the affected upper limb
2. improve upper limb motor function
3. improve walking ability
53
What are 6 types of Neuromuscular Stimulation (Enhancing via Electrical Stimulation)?
1. Electrodes: external or internal (Vagal)
2. Contraction produced vs no contraction produced
3. Paretic limb inactive vs active (EMG triggered Electrical Stimulation)
4. Constant vs intermittent stimulus
5. Functional Electrical Stimulation (FES)
6. Various combinations of the above types
54
What are 6 benefits of Electrical Stimulation?
1. Allows independent practice
2. Allows practice in range where voluntary movement is not possible
3. Encourages attention to body part
4. Reassures patient that muscle activity is possible
5. Stimulation is proposed to maintain nutrition of muscle cells and neurons
6. Easy to operate, portable, simple units are inexpensive
55
What is the evidence for the use of ES to increase strength?
efficacy of electrical stimulation for increasing voluntary strength in people with neurological conditions
56
What are the 4 clinical implications for the use of ES to increase strength?
1. ES appears to enhance muscle strength when applied to weak muscles after stroke
2. It is not clear whether ES is as effective as progressive resistance training
3. It is not clear if ES confers additional benefits when used in conjunction with PRT
4. At this stage recommend combining ES with PRT
57
\_\_\_\_\_ is effective at improving gait speed in subjects poststroke
FES
58
What are the typical parameters for Eletrical Stimulation?
* Rate/frequency (Hz): 30‐100Hz
* Wave form: subject preference
* Duty cycle: 10‐15s on:15‐30s off
* Intensity: maximum tolerated
* Number of contractions: until fatigue
* Frequency of sessions: \>3/week
59
What is the evidence for ES for glenohumeral subluxation and hemiplegic shoulder pain?
1. increasing passive ROM (lateral rotation of paretic shoulder)
2. reduction of caudal subluxation in favour of NMS
\*\*\*Insufficient evidence found for reducing hemiplegic shoulder pain
60
What is the protocol for ES for glenohumeral subluxation?
61
What are 3 ES units commonly used?
62
What are 3 uses of equipment to decrease friction and increase ease of movement?
1. Slideboards
2. Skateboards
3. BedEx mats
63
Preliminary evidence that PRST (Progressive Resistance Strength Training
can increase ______ after stroke.
muscle strength
64
There is currently ______ (no evidence/evidence) that strength training increases spasticity or reduces range of movement
no evidence
65
What are 4 PRE considerations?
1. Improvements in muscle strength do not necessarily directly equate with improved function
2. Program must always include functional training
3. More recent studies combine task-oriented exercises with PRE
4. Other impairments which may impact on function must also be assessed and addressed if required
66
What are 5 strengthening interventions = interventions that involved attempts at repetitive, effortful muscle contractions?
1. biofeedback
2. electrical stimulation
3. muscle re‐education
4. progressive resistance exercise
5. mental practice
67
What are 3 conclusions of combined strengthening interventions?
1. Strengthening interventions
2. Had a small positive effect on strength and activity
3. Did not increase spasticity
68
What are the clinical implications of combined strengthening interventions?
Strengthening programs should be part of rehabilitation after stroke
69
What are 3 characteristics of "Enhance via Destabilising Surfaces"?
1. Labile surfaces
* e.g. gym balls
* 3 dimensional, multidirectional, mobile conditions
* Myriad of uses
2. Pivoting conditions
* Used to stimulate balance reactions
3. Compliant surfaces
* e.g. foam and inflatable discs
* Used during weight bearing activities to:
* mimic environmental conditions stimulate muscle interplay (particularly at the ankles)
* Stimulate balance responses
70
What is a Low Friction Surface (destabilising surface)?
Low Friction Surfaces
* e.g. BedEx Slider Mat
71
Development of new assistive _____ that allow clients to practice more intensively on their own
technologies
72
What are 7 characteristics of MOTOmed movement therapy machine?
1. Cycle ergometer
2. Upper or lower limbs
3. Passive, assistive and active training
4. Voluntary movement detection
5. Spasm detection
6. Tone reduction
7. Symmetry training
73
What are 2 characteristics of virtual reality?
1. Computer technology that simulates real‐life learning
2. Allows for repetitive intensive practice and provides augmented sensory feedback
74
What are the 2 uses of robtics in stroke rehabilitation?
1. to supplement the use of therapists
2. to provide more intensive therapy
75
What is activated when there is compression of joint? WHat is activated when there is distraction of joint?
Compression of joints: activate extensors
Distraction of joints: activate flexors
76
What is the handling for quick stretch in sitting and in supine?
Sitting
* Set patient up for success (optimal posture)
* Load the arm (compression, proprioception- extensors)
* Try not to let the arm buckle - this can be determined by position of arm/hand
* Enhancing and replacing the support of elbow and shoulder
* Can try to move the arm through range - try to activate muscles (do not move body load off)
Supine
* Target triceps
* Slowly let go and give quick slow taps on wrist (to lift)
* Stroke proximally (elbow to shoulder direction) for tactile feedback
77
What is the handling stabilisation (guidance target)?
* IR and pronated --\> hard to do activities (make sure thumb/fingers does not curl in)
* Try to keep in neutral position (optimal alignment)
* Replace or enhance (tap triceps)
* Always have a mirror (to check patient)
* Train inattention in the inattentive space (eg. train left limb in the left side/area if left hemi)
78
79
What is the evidence for FES to improve gait speed Evidence of efficacy?
FES is effective at improving gait speed in subjects poststroke
* Unsure of long term, but very effective in immediate effect
