Test NDT Fall 2015 Flashcards
(313 cards)
1
Q
Initial Swing
Gait components
A
Anterior Elevation
Concentric by
- hip flexors
- abdominals
- contralateral extensors
2
Q
Late swing to initial contact
Gait components
A
Anterior depression
eccentric by posterior elevators
3
Q
Midstance to tow off
Gait components
A
Posterior Depression
Concentric/isometric
4
Q
Very Initial Swing
Gait components
A
Posterior elevation
Plus anterior elevation
Cocontraction
5
Q
What must be covered in advanced PNF for gait? (3)
A
- Pre-gait activities
- Individual Components
- Gait: whole skill training
6
Q
Special techniques: why we use them in advanced PNF
A
- for insufficiently activated muscles
- for partially activated muscles
- For well-activated muscles
7
Q
Using basic patterns: advanced PNF
for gait
3 things to do
A
1) Posterior depression with D1 Extension
2) Massed trunk extension using pelvis and scapula
3) Reciprocal trunk
8
Q
Using Learning sequence pre-gait activities
3 positions to try
A
- Quadruped:
- early swing components - Backwards crawling:
- posterior depression with leg extension - Single limb support:
- resisted high step
- resisted anterior elevation of pelvis emphasizing knee control from flexed to extended positions
- resisted anterior elevation during push-off with hip extended
9
Q
Why quadruped for pre-gait activities
A
early swing components
10
Q
Why backwards crawling for pre-gait activities
A
posterior depression with leg extension
11
Q
Why single limb support for pre-gait activities
A
- resisted high step
- resisted anterior elevation of pelvis emphasizing knee control from flexed to extended positions
- resisted anterior elevation during push-off with hip extended
12
Q
Resisted Gait
what are the components
1) at the end of swing and heel strike
2) at the very end of stance and /initial swing transition
A
1) Eccentric posterior elevation/ depression at the end of swing and heel strike
2) isometric holding posterior elevation at the very end of stance/initial swing transition
13
Q
Resisted Gait
what happens in backward walking
A
Resisted posterior elevation
14
Q
Resisted gait
forward walking using dowel
A
Select one part of the cycle (weight transference, push-off and swing) and repeatedly resist it through the dowel
15
Q
NDT Models of Care
Body Structure and Function
- -Functional Domain
- -Disability Domain
A
–Functional Domain
Structural and Functional Integrity
–Disability Domain
Primary and Secondary Impairments
16
Q
NDT Models of Care
Motor Functions
- -Functional Domain
- -Disability Domain
A
–Functional Domain
Effective Posture and Movement
–Disability Domain
Ineffective posture and movement
17
Q
NDT Models of Care
Individual Functions
- -Functional Domain
- -Disability Domain
A
–Functional Domain
Functional activities
–Disability Domain
Functional activity limitations
18
Q
NDT Models of Care
Social Functions
- -Functional Domain
- -Disability Domain
A
–Functional Domain
Participation
–Disability Domain
Participation restriction
19
Q
Primary impairments
what is it
2 examples
A
directly due to pathophysiology
related to pathophysiology:
- weakness
- hemiparesis related to stroke
20
Q
Secondary Impairments:
what is it
2 examples
A
not directly due to pathophysiology, develop over time
- ROM
- learned disuse
21
Q
Motor dimension
A
domain of posture and movement function / dysfunction :
how the motor status progresses or regresses over time
22
Q
Domain of posture and movement dysfunction
A
The continue from effective to ineffective posture and movement in a dimension of motor function is unique in the NDT enablement model.
The NDT approach identifies and analyzes patterns of posture and movement that link functional abilities with underlying systems
Trunk control affects extremity movements
Proximal control: focus comes at trunk initially and then to extremities. Can treat distally if that is what is available to you but historically was more proximal then distal.
23
Q
The continuum from effective to ineffective ____ and ____ in a dimension of motor function is unique in the NDT enablement model.
A
The continue from effective to ineffective posture and movement in a dimension of motor function is unique in the NDT enablement model.
24
Q
Domain of posture and movement dysfunction
The NDT approach identifies and analyzes patterns of ____ and _____ that link functional abilities with underlying systems
A
The NDT approach identifies and analyzes patterns of posture and movement that link functional abilities with underlying systems
25
Why do we focus on trunk control in NDT
Trunk control affects extremity movements
Proximal control: focus comes at trunk initially and then to extremities. Can treat distally if that is what is available to you but historically was more proximal then distal.
26
Domain: Individual Functions:
Functional Activity limitations: range from simple tasks to complex skills
in an NDT approach it is the specific job of the clinician to identify functional limitations, then to theorize which motor dysfunctions and system impairments are responsible for limitations in the client’s behavior.
NDT examination focuses on difference in performance and capacity as it relates to function in various settings and uses this information to determine strategies for interventions that might bridge the gap between the two.
27
Functional Activity limitations:
in an NDT approach it is the specific job of the clinician to identify _______, then to theorize which ________ and _______ are responsible for limitations in the client’s behavior.
in an NDT approach it is the specific job of the clinician to identify functional limitations, then to theorize which motor dysfunctions and system impairments are responsible for limitations in the client’s behavior.
28
Functional Activity limitations:
NDT examination focuses on difference in _____ and ____ as it relates to function in various settings and uses this information to determine strategies for interventions that might bridge the gap between the two.
NDT examination focuses on difference in performance and capacity as it relates to function in various settings and uses this information to determine strategies for interventions that might bridge the gap between the two.
29
Functional Activity limitations:
NDT examination focuses on difference in performance and capacity as it relates to ______ in various settings and uses this information to determine strategies for interventions that might bridge the gap between the two.
NDT examination focuses on difference in performance and capacity as it relates to function in various settings and uses this information to determine strategies for interventions that might bridge the gap between the two.
30
Functional Activity limitations:
Takes primary impairment and secondary impairment and go forward to address the ______: a task analysis. Take a task they cannot do i.e. getting dressed in the morning. Break it into components-why cannot do it. Motor control to grab shirt, ROM in elbow or hand to grasp the shirt. Dysfunction in shoulder. Break it down and find the treatment accordingly.
Takes primary impairment and secondary impairment and go forward to address the functional limitation: a task analysis.
Take a task they cannot do i.e. getting dressed in the morning. Break it into components-why cannot do it. Motor control to grab shirt, ROM in elbow or hand to grasp the shirt. Dysfunction in shoulder. Break it down and find the treatment accordingly.
31
GIVE AN EXAMPLE
NDT: functional activity limitations
Takes primary impairment and secondary impairment and go forward to address the functional limitation: a task analysis.
Takes primary impairment and secondary impairment and go forward to address the functional limitation: a task analysis.
Take a task they cannot do i.e. getting dressed in the morning. Break it into components-why cannot do it. Motor control to grab shirt, ROM in elbow or hand to grasp the shirt. Dysfunction in shoulder. Break it down and find the treatment accordingly.
32
Social Dimension:
what is it the domain of?
Participation and Participation Restrictions
33
Social Dimension:
what does it take into account?
(3)
1. Expected performance,
2. activity, and
3. roles within physical and social contexts
-What you would expect them to do in their home etc.
-It may be they don't care about that task and any practice you give them isn't going to help that task, choose to work on something they care about.
Not just reaching for cone but something that interests them. Do things that are important to them and they will be more engaged
34
Facilitators / Barriers or Hindrances:
Individual Factors
Services and systems
individual factors: Are elements in the immediate personal environment of the individual, including but not limited to settings such as home, workplace, community, and school.
Services and systems include formal and informal social structures and services in a community that affect an individual, such as organizations and services related to work environment, community activities, government agencies, communication, and transportation services.
35
Facilitators / Barriers or Hindrances:
Individual Factors
what are they?
Elements in immediate personal environment of the individual, including but not limited to
settings such as home, workplace, community, and school.
36
Facilitators / Barriers or Hindrances:
Services and systems
Services and systems include formal and informal social structures and services in a community that affect an individual, such as
organizations and services related to work environment, community activities, government agencies, communication, and transportation services.
37
Contextual Factors:
what are they?
give an example:
Use specific environmental context to shape patterns of movement.
-constraint induced therapy uses environment and little handling to shape the activity
—want someone to reach up and manipulate something on a shelf to get a hand to get the hand shape and reach you want rather than asking someone to do that.
Folding towels, set up child in a playground or outside or community setting.
38
Contextual Factors:
What is the NDT Focus:
what it helps with
Impact of the specific ENVIRONMENT in shaping the PATTERNS OF MOVEMENT
Additional avenues for intervention strategies.
This attention to the dynamic interactions between the individual and the environment reflects a change in NDT focus.
Constraint induced: uses the environment and little handling to shape the task—the context of the activity—reach up and manipulate something—automatically getting the motion you want
39
Atypical alignment and abnormal patterns of WB
3 possible causes
Examples:
1. neuropathology (Pusher’s Syndrome)
2. musculoskeletal impairments
3. compensation for weakness.
Shoulder subluxation, or gradually increasing pronation in the foot.
If you can influence the patient’s alignment you can change the way they move. (Changing joint kinematics, muscle length/tension relationships, and sensory input)
40
Why do we care to influence the patient’s alignment?
If you can influence the patient’s alignment you can change the way they move.
(Changing joint kinematics, muscle length/tension relationships, and sensory input)
41
Abnormal Muscle Tone:
hypertonia and hypotonia
| usually flaccidity or hypotonia in the beginning, and then progress to hypertonia
42
Causes of hypertonia
5
1. spasticity
2. Changes in muscle properties
3. Changes in adaptability of muscles
4. Stiffness (or muscle elasticity)
5. Abnormal force production (hypotonia as well)
43
spasticity:
spasticity: velocity dependent reaction to stretch (only one component of increased muscle tone)
44
Hypertonia:
Changes in muscle properties:
3
hypoextensibility, contracture, and muscle atrophy
1. can lose MU
2. more connective tissue overlay
3. weaker and stiffer
45
Hypertonia
Changes in adaptability of muscles:
3
Changes in adaptability of muscles:
1. excessive co-activation
difficulty isolating biceps and triceps and turn on both at the same time
2. DF and PF kick in at the same time (try to position on side for different sensory input)
3. if tight muscle this will also affect sensory input: changes proprioception in the area and feedback you get from the limb. Use a quieter voice. Change the activity if stuck in a pattern with a lot of co-activation. help them gain control over a different position.
46
Hypertonia
Stiffness
Stiffness (or muscle elasticity)
47
Hypertonia
Abnormal force production
Abnormal force production (hypotonia as well)
48
Kinesiological and Biomechanics Components of Movements:
What causes differences in postures and movements that occur between infancy and adulthood?
(3)
1. kinesiological / biomechanics components of the musculoskeletal system
2. anthropometric changes
3. movement experiences in various gravitational contacts
(get swelling, and postural and gravitational responses affect how you move, practice under NDT: look at biomechanics, musculoskeletal factors of joint mobility)
49
NDT: Coordination Problems:
impaired coordination results from the disruption of the activation, sequencing, timing, and scaling of muscle activity, all of which have been discussed as primary impairments in CNS pathology.
impaired coordination results from the disruption of the activation, sequencing, timing, and scaling of muscle activity, all of which have been discussed as primary impairments in CNS pathology.
50
NDT: Coordination Problems:
What does impaired coordination results from?
The disruption of the activation, sequencing, timing, and scaling of muscle activity, all of which have been discussed as primary impairments in CNS pathology.
51
NDT: Coordination Problems:
What primary impairments in CNS pathology cause impaired coordination?
Disruption of___
(4)
1) Activation
2) sequencing
3) timing,
4) scaling of muscle activity
52
Ruskin:
CNS white matter
The largest amount of CNS white matter is used in:
feedback and feedforward communication
In redundant feedback loops and feedforward communication and interrelating of cells—> everything is intergraded and utilized
53
Implication of Ruskin on CNS white matter
1. Associated problems: Motor planning and understanding of feedback confused: may take more time and repetition to understand an activity—need to try it more than one before you give up on the activity.
2. Everything is integrated and both sides of the body are utilized
3. Recovery after stroke as long as some sparing healthy tissue there is prospect that improvement will occur--> Patient can have problems in areas you did not think there would be problems
54
Implications of Ruskin on white matter
Motor planning and understanding of feedback can get confused:
So when set up a clear activity may take more time and set up and repetition. —may need to try it more than once and in different contexts before giving up on doing it.
55
Who said
there is no such thing as a single stroke with hemiplegia
Ruskin: Motor control integration—ruskin—there is no such thing as a single stroke with hemiplegia
56
Explicit and implicit motor learning:
Boyd and Winstein:
After MCA stroke:
explicit info was detrimental for implicit motor learning –a lot of VC will not be beneficial—environment, tactile, an be helpful to include
If medial temporal lobe damage had explicit learning deficits—a lot of verbal cues not help
use hand placements and guidance and context and environment
Implicit system is spread out and so it does not get completely disrupted: because it is so distributed: cerebellum, basal ganglia, SMC (sensory motor cortex)
57
What happened to explicit learning after stroke?
detrimental for implicit motor learning
–a lot of VC will not be beneficial
-environment, tactile, an be helpful to include
If medial temporal lobe damage had explicit learning deficits—a lot of verbal cues not help
use hand placements and guidance and context and environment
58
What damage caused explicit learning deficits
MEDIAL TEMPORAL LOBE damage had explicit learning deficits—a lot of verbal cues not help
59
What learning is messed up after MCA stroke?
explicit info was detrimental for implicit motor learning –a lot of VC will not be beneficial—environment, tactile, an be helpful to include
60
Will VC work after MCA stroke?
If medial temporal lobe damage had explicit learning deficits—a lot of verbal cues not help
use hand placements and guidance and context and environment
61
Will Implicit learning be messed up after stroke?
Implicit system is spread out and so it does not get completely disrupted: because it is so distributed: cerebellum, basal ganglia, SMC (sensory motor cortex)
62
Medial Temporal Lobe
- Implicit Learning Strategies
- Explicit Learning Strategies
Implicit Learning Strategies
UNIMPAIRED
Explicit Learning Strategies
IMPAIRED
63
Prefrontal Cortex
- Implicit Learning Strategies
- Explicit Learning Strategies
Implicit Learning Strategies
IMPAIRED: Visiomotor Sequencing Task
Explicit Learning Strategies
IMPAIRED: Visiomotor Sequencing Task
64
MCA: Sensorimotor Cortex
- Implicit Learning Strategies
- Explicit Learning Strategies
Implicit Learning Strategies
Unimpaired
Explicit Learning Strategies
Impaired
65
Cerebellum
- Implicit Learning Strategies
- Explicit Learning Strategies
-Implicit Learning Strategies
Unimpaired
-Explicit Learning Strategies
Impaired
66
Problems related to disturbed perception:
| 4
1. Difficult to describe
2. Must be observed
4. Bilateral loss of discriminative sense in some modalities
4. Dressing-Non motor aspects
67
Which specific sensory systems: do we need to evaluate?
| 3
1. somatosensory
2. Vestibular responses
3. Vision, hearing, etc
68
Cortical or Discriminatory Sensations / Functions
| 4
1. Kinesthesia:
- Passive position senses
- Passive motion sense
2. Point Localization
3. Stereognosia, Graphesthesia etc
4. Tactile Extinction
69
Lesions of the Association Cortices:
What happens (6)
Body image
- Hemineglect
- Body part identification
- Anosignosia
- Topographic Orientation, Figure--Ground Relationships
- Agnosia
70
Motor Planning Issues:
Lesions of the Association Cortices:
2 types
```
1) Apraxias:
1-construction apraxia,
2-dressing apraxia,
3-ideomotor apraxia,
4-ideational apraxia
```
```
2) Cognitive problems
1-attention
2-memory
3-problem solving
4-new learning ability
```
-Explicit motor learning strategies: following instructions of others
-Implicit motor learning strategies:
From within the learner, learning through repetition
More diffusely distributed throughout the brain
Lesion site may determine one’s ability to use explicit vs implicit strategies
71
4 types of apraxias with Lesions of the Association Cortices:
1-construction apraxia,
2-dressing apraxia,
3-ideomotor apraxia,
4-ideational apraxia
72
4 Cognitive problems with Lesions of the Association Cortices:
1-attention
2-memory
3-problem solving
4-new learning ability
73
What are Explicit motor learning strategies?
Explicit motor learning strategies:
following instructions of others
74
What are Implicit motor learning strategies?
-Implicit motor learning strategies:
From WITHIN THE LEARNER
learning through repetition
More diffusely distributed throughout the brain
Lesion site may determine one’s ability to use explicit vs implicit strategies
75
Patient may have sensory and perceptual problems-may come across as excuses for not doing something, poor carryover, not interested but may be aphasic, social behavior doesn't match, difficulty adapting
Patient may have sensory and perceptual problems-may come across as excuses for not doing something, poor carryover, not interested but may be aphasic, social behavior doesn't match, difficulty adapting
76
Medial Temporal Lobe
Implicit not impaired
Explicit impaired
77
Prefrontal Cortex
Implicit impaired (visiomotor sequencing task)
Explicit impaired (visiomotor sequencing task)
78
MCS: Sensorimotor cortex
implicit unimpaired
explicit impaired
79
Cerebellum
implicit unimpaired
explicit impaired
80
What do we need to evaluate in sensory motor therapy?
Specific sensory systems
1. somatosensory
2. vestibular responses
3. vision, hearing, etc.
81
What are the somatosensory sensations?
| 6
1. primary sensations (light and deep touch, pain and temperature, vibration sense)
2. cortical or discriminatory sensations/functions
3. Kinesthesia (passive position sense, passive motion sense)
4. point localization
5. stereognosia, graphesthessia, etc
6. tactile extinction
82
What are perceptual problems?
Lesions of the association cortices
Body Image
a) Hemineglect
b) Body part Identification
c) Anosignosia
d) Topographic Orientation, figure-ground relationships
e) Agnosia
83
What are motor planning issues?
Apraxias:
- constructional apraxia
- dressing apraxia
- ideomotor apraxia
- ideational apraxia
cognitive problems
- attention
- memory
- problem-solving
- new learning ability
84
Explicit motor learning strategies:
following instructions of others
85
Implicit motor learning strategies:
From within the learner, learning through repetition
More diffusely distributed throughout the brain
Lesion site may determine one’s ability to use explicit vs implicit strategies
86
What are some common problems associated with disrupted perception?
Hypertonicity
Adopting end range Joint Positions
Hyperactivity, and Inordinately quick responses to commands
Pressing too hard against support surfaces
Hyperactivity, and indornitaly quick reps uses to commands
use of far too much effort when performing simple activities
inability to perform tasks despite adequate muscle activity
Inability to remember appointments, instructions, corrections which have been given previously
Failure to preserve stimuli on affected side
urinary incontinence
Non-valid explanations for failed task performance
Poor carryover
Apparent loss of initiative
Aphasia
Social behavior does not match situation
Difficulty adapting behavior
Disturbed perception and learning
Implications for learning
Guided movement therapy: intensive guiding
87
Right Fit Task Analysis
If the task is at the right level the patient will:
(4)
1. Work quietly and is not moving restlessly
2. Tone throughout his body will ‘normalize’ regardless of whether hypotonia or hypertonia is the predominate problem
3. Intent facial expression
4. Eye contact for task is appropriate
88
Poor Fit Task Analysis:
Too Complex
1. Patient shows panic or fear
2. Tone increases markedly
3. He talks exaggeratedly about irrelevant matters
4. Makes constant requests to visit the toilet
5. Complains of other symptoms which could account for his lack of success
6. Shows signs of aggression to the therapist or nurse
89
Right fit task analysis
Too Easy:
Too Easy:
1) Patient appears bored or disappointed
2) Chatters inconsequently or makes repetitive jokes
3) Is inattentive
4) Fiddles with clothing, scratches
90
Physical Factors Affecting Guiding
| 4
1) Size of patient - positioning
2) Mechanical factors
3) Patient’s stage of progress
4) Location
91
Things to pay attention to in a case study for adults with hemiplegia
participation restriction
functional limitation
postural and movement limitations
system impairments
musculoskeletal system
sensory systems
respiratory sustem
92
Documentation
What do goals need to address
3
1) FUNCTIONAL LIMITATIONS
2) and the IMPAIRMENTS that lead to them
3) (also ENVIRONMENTAL CONSTRAINTS)
why cant foot go onto the step
why cant stand up without fallling backwards
93
Documentation
How goals need to be constructed
Mini goals for the session assess and reassess, be persistent.
step back from the situation and try to analyze what you can improve on in the next session—PLACEMENT of the task, CHOICE of the task, MODIFICATION, HANDLING
Use of reliable and valid MEASURES -goniometry, berg balance scales, fugl meyer assessment
94
What needs to be in goals
Assess, reassess
Placement of task
Choice of task
Modification
Handling
Measures: goniometry, berg, fugl meyer
Address:
1) FUNCTIONAL LIMITATIONS
2) and the IMPAIRMENTS that lead to them
3) (also ENVIRONMENTAL CONSTRAINTS)
95
Factors important for patient prognosis
| 6
1) Medical history/stability
2) Social supports / family role and contribution
3) Management of depression, grieving process, acceptance
4) Severity of perceptual and cognitive deficits
5) First acute event vs chronic repeated events
6) Therapist attitude and ability to provide appropriate learning environment for patient
96
Umphred : 3 categories of human movement
1) normal and functional;
2) functional but limited in adaptability
3) dysfunctional and abnormal
97
Analysis leading to appropriate intervention
4 steps
1. look at any movement pattern
2. evaluate its components
3. identify what is missing
4. incorporate treatment strategies that help the client achieve the desired function outcome
98
Neuroplasticity: Implications for Neurorehabilitation
| 6 types of interventions that are used
6
1) Mirror therapy
2) Robotics
3) Body Weight Supported Treadmill Training
4) Constraint induced movement therapy
5) Virtual Reality
dual task cognitive training
6) Lesion site and dominance factors
99
Mirror Therapy--how many repetitions?
Able to achieve greater than or equal than or equal to 300 repetitions
session in the study high numbers of repetition have been shown to benefit patients post stroke
100
Cognitive Aspects of Intervention
| 4
1) Target FUNCTIONAL and COGNITIVE training
2) High REPETITIONS for high priority activities
(especially if memory and praxis issue, shorter task bouts if attention deficit)
3) focus on providing interesting and motivating activities to practice
4) language comprehension problems: greater focus on somatosensory, visual, thermal, and deep sensation for motor learning
101
How to incorporate
How is your role in society impacted by a mobility impairment?
Look at the whole person and what is meaningful to them functionally-this is where you will find your most effective tx –it is not an easy quick process
102
NDT handling and key points of control
OPEN HAND POSTURE
--not lumbrical grip and not on bony prominences
--Contact on MUSCLE BELLIES
–input GRADED not constant, and should be as LIGHT as possible achieve the desired results
103
What are you looking for in handling in NDT
Looking for a MUSCLE CONTRACTION under your hand
104
Examples of NDT handling
open hand posture on muscle bellies, look for a muscle contraction
-Ie gluteal muscles, quadriceps/hamstrings—not mixing muscle groups (not input to both hamstrings and quads unless you want them both to fire)
- Handling the foot
- Bottom of foot will make curl (if grip into the bottom of the foot)
105
LE impairments
3 things to assess
1) strength
(concentric/eccentric-task specific training and closed chain activities are usually best )
2) coordination
3) sensory impairments –provides sensory experiences, weight bearing appropriate handling,
ie appropriate key points, encouraging muscle activation for further feedback to the sensory system
106
Movement Analysis:
1) Joint kinematics are needed to complete the task, reliability
2) Strength (and muscle specifically concentric and eccentric) throughout body that make the movement possible
3) Feedback needed to improve timing and coordinated control
4) Targeted treatment and compensations that are necessary
107
What is the NDT approach
| 6
1. Identify FUNCTIONAL TASK you want to improve
2. Identify FUNCTIONAL IMPAIRMENTS that prevent the task from being accomplished
3. Develop MINI GOALS to address each impairment individually and then as a whole
4. Plan TREATMENT accordingly
5. PRE-TEST / POST-TEST
6. ANALYZE RESULTS
108
LE impairments
NDT: what to address
1) IMPAIRMENTS are a place to start
2) Remember that the ALIGNMENT of the PROXIMAL SEGMENTS (especially trunk) will impact ability of patient to use LE
3) MUSCLE TONE: too high/too low management strategies
4) ROM: specific joint ranges need to be available – stretching , joint mobilizations
5) STRENGTH: concentric/eccentric
6) COORDINATION
7) SENSORY IMPAIRMENTS
109
LE Function in Sitting
```
ALIGNMENT
Hips:
Knees:
Ankle:
Foot:
Trunk:
```
Hips: abducted to neutral, flexed to 90 degrees
Knees: flexed to 90 degrees
Ankle: DF to neutral
Foot: able to rest on surface with neutral supination/pronation, toes in neutral abduction/extension, balance of muscle activity
Remember trunk is assumed to be in good alignment as well: neutral lumbar spine, thoracic extension
110
Something to do to aid in LE function in sitting
Soft tissue mobilization of talus to improve DF, metatarsal spread, toes
111
Standing
ALIGNMENT
HIPS
KNEES
ANKLES
FOOT
HIPS: extended to neutral, feet hip width apart
KNEES: extended, not resting on ligaments
ANKLES: DF to at least neutral (ideally more should be able to allow for efficient postural sway)
FOOT able to rest on the surface, arches are maintained.
Toes extended, not over or under active
112
For standing:
when is it good to have UE supported? (3)
when do we not want UE supported? (2)
WANT
1) safety
2) balance
3) good for the arm —appropriate postural responses is good for the CNS and can encourage active control
DON'T WANT
1) working on balance
2) to add complexity to the task cognitively
- -----if painful: if still want support can have the elbow flexed and leaning through forearms
113
LE facilitation
key points:
Trunk, quadriceps/hamstrings for weight shifting laterally and anterior/lateral
114
Sit to Stand:
1. Weight shift (anterior)
2. Muscle activity
3. Facilitation: Key Points:
- --Trunk (abdominals and lumbar extensors)
- --Lower Extremities: Hip extensors/ knee extensors (from anterior position)
- --From lateral position
115
Sit to Stand:
what muscle activity needed
TRUNK: Balance of flexion/ extension
HIPS: flex to 110 degrees (depends on height of surface) then extend,
KNEES: may move towards increased flexion with anterior weight shift/ scoot forward,
ANKLES: dorsiflexed, then plantarflexed
116
How much do hips need to be flexed in sit to stand?
110 degrees (depends on height of surface) then extend
117
Facilitation needed in sit to stand
Key points (3)
1) Trunk (abdominals and lumbar extensors)
2) Lower Extremities: Hip extensors/ knee extensors (from anterior position)
3) From lateral position
118
Weight Bearing Sequence in Standing:
| 4
1) Bilateral Knee Bends
2) Shift to involve LE with “release” of uninvolved knee
3) Shift to involved LE, toe in/ toe out with uninvolved foot
4) Shift to involved LE, step forward with uninvolved LE
119
Walking/Gait Initiation
Components
Components:
| single limb support, double limb support
120
Walking/Gait Initiation
Key points
Gluteus medius, quadriceps/hamstrings (in stance on stance limb)
121
Walking/Gait Initiation
- components
- foundations: key points
- activity to do for WS
Components: single limb support, double limb support
Foundation: Key Points: Gluteus medius, quadriceps/hamstrings (in stance on stance limb)
What to do with the UEs?
Stance Standing
Step ons to work on weight shifting and single limb stance (sensory implications?)
122
Facilitation of Gait: Group exercise
-key points of control
--what to consider about the input
Group exercise: following
Key Points of control: trunk laterally, gluteus medius, quadriceps/hamstrings, UE
Now without talking try to direct/ influence partner
```
Timing of input,
intensity of input,
withdrawing input (moving distally, less intense, less frequent)
```
123
Common Gait Impairments Following Stroke
STANCE (2)
SWING (2)
STANCE
1. Decreased hip extension at end of stance
2. Decreased DF at foot contact and during stance associated with hyperextended knee
SWING
1. Decreased knee flexion at toe off and mid swing
2. Decreased hip flexion mid swing
124
Common Gait Impairments Following Stroke
STANCE (2)
1. Decreased HIP EXTENSION at end of stance
| 2. Decreased DF at foot contact and during stance associated with hyperextended knee
125
Common Gait Impairments Following Stroke
SWING (2)
1. Decreased KNEE FLEXION at toe off and mid swing
| 2. Decreased HIP FLEXION mid swing
126
Common Gait Impairments Following Stroke
When is there decreased hip extension?
STANCE
Decreased HIP EXTENSION at end of stance
127
Common Gait Impairments Following Stroke
When is there decreased DF?
STANCE
Decreased DF at:
1. foot contact
2. during stance associated with hyperextended knee
128
Common Gait Impairments Following Stroke
When is there decreased knee flexion?
SWING
Decreased KNEE FLEXION at:
1) toe off
2) mid swing
129
Common Gait Impairments Following Stroke
When is there hip flexion?
SWING
Decreased HIP FLEXION mid swing
130
Abnormalities that may be seen in swing phase
| 6
1) hip hike, circumduction
2) decreased hip flexion
3) foot drop
4) may see a synergy at hip
flex/knee flex/df
5) difficulty self advancing the leg
6) decreased knee flexion at toe off/terminal swing
131
Abnormalities that may be seen in stance phase
1) knee hyperextension: :
2) knee buckle
3) trenndelenburg
4) trunk excess lateral tilt
5) lack hip extension
6) scissoring or other incorrect foot placement
7) decreased ankle DF at foot contact during stance
132
When may knee hyperextension be seen in stance phase?
initial swing / midstance / terminal stance:
If start with leg extended then will need to work on loading response and get the idea of taking a smaller step onto a flexed knee and then coming over it.
Patients feel need to lock knee to stabilize.
133
Stair Negotiation:
What is needed for ascent?
Ascent:
High concentric demand on Knee and ankle (mostly KNEE)
134
Stair Negotiation:
What is needed for descent?
Descent:
anticipatory muscle contraction in swing leg prior to step contact-gastroc/soleus
135
What is needed during stair negotiation?
ASCENT: High concentric demand on Knee and ankle (mostly knee)
Stability demands are highest when the swing leg is advancing to the next step for ascent
DESCENT: anticipatory muscle contraction in swing leg prior to step contact-gastroc/soleus
136
When are stability demands highest on stair negotiation?
Stability demands are highest when the swing leg is advancing to the next step for ascent
137
DVT:
SWELLING of the leg or along a vein in the leg.
PAIN or tenderness in the leg, which you may feel only when standing or walking.
Increased WARMTH in the area of the leg that's swollen or painful.
Red or discolored skin on the leg.
1. swelling
2. redness
3. very painful
Also pain on WB is another signal that something needs to be followed up before doing this
138
UE tx sequence
```
spinal mobility/alignment,
weight bearing,
body on arm
-->
arm on body,
isometric,
eccentric,
concentric,
Contralateral to ipsilateral movements
```
139
UE anatomy*learn it
Know anatomy******
The hand—can get pain, fractures
Forearm and wrist: When you facilitate movements remember for supination and pronation where the muscles run
Shoulder girdle: if it is abducted and upward rotated or if there is an alignment that is not normal
140
Why need to work Latissimus Dorsi?
need to work on the shoulder because the pelvis and scapula are interrelated –if tight get internal rotation and hip in bad position –lateral trunks stretching can help with walking and reaching and general WB on that side
141
Scapular movements: closed chain—the way the scapula moves based on the position of the trunk
Trunk Flexion :
aBduction,
slight elevation,
downward rotation
142
Scapular movements: closed chain—the way the scapula moves based on the position of the trunk
Trunk Extension :
aDduction to neutral,
depression,
upward rotation to neutral,
approximation
143
Scapular movements: closed chain—the way the scapula moves based on the position of the trunk
Lateral WS: Towards arm
stays depressed,
aBducts slightly,
maintain neutral rotation,
approximates
144
Scapular movements: closed chain—the way the scapula moves based on the position of the trunk
Lateral WS: Away from arm
stays depressed,
aDducts,
rotates down,:
depends on length of arm,
approximates
145
Scapular movements: closed chain—the way the scapula moves based on the position of the trunk
Trunk Rotation on Midline: Turning toward the arm:
stays depressed,
aDducts,
slight downward rotation
146
Scapular movements: closed chain—the way the scapula moves based on the position of the trunk
Trunk Rotation on Midline:
Turning away from the arm:
stays depressed,
aBducts
147
Scapular movements: closed chain—the way the scapula moves based on the position of the trunk
Forward Bend With Trunk Extension
Scapula stays depressed
Stays neutral rotation
ADducts amount depends on arm length
148
UE Function WB Sequence:
Starting alignment:
Sitting, feet are hip width apart in 90-90 position of hips, knees, and ankles. Upright and active trunk. [There should be a balance between abdominals and spinal extensors]
Uninvolved arm: Can be placed on upper thigh or alternatively on edge of mat. Do nautical uninvolved arm further forward or higher than the involved side
Involved arm:
-Scapula: stable against the thorax in slight abDuction and upward rotation
- Shoulder: humerus is away from the trunk in slight flexion, aBduction, and lateral rotation (elbow crease is forward)
- Elbow: between 90 degrees of flexion and complete extension so that the hand is lower than the elbow
Note: elbow should be more extended if the tone is low, and more flexed if high tone is present.
- Forearm: pronated
- Wrist: Neutral in radial/ulnar deviation. Neutral to wrist extension (depending on amount of elbow flexion).
- Hand: open on a WB surface. The arch of the hand should be preserved if possible.
149
UE Function WB Sequence:
Starting alignment
Starting alignment:
Sitting, feet are hip width apart in 90-90 position of hips, knees, and ankles. Upright and active trunk. [There should be a balance between abdominals and spinal extensors]
150
UE Function WB
Sequence:
Uninvolved arm:
Uninvolved arm:
Can be placed on upper thigh or alternatively on edge of mat. Do not place uninvolved arm further forward or higher than the involved side
151
UE Function WB Sequence:
Involved arm:
-Scapula:
Involved arm:
| -Scapula: stable against the thorax in slight abDuction and upward rotation
152
UE Function WB Sequence:
Involved Arm:
-Shoulder:
-Shoulder: humerus is away from the trunk in slight flexion, aBduction, and lateral rotation (elbow crease is forward)
153
UE Function WB Sequence:
Involved Arm:
elbow
-Elbow: between 90 degrees of flexion and complete extension so that the hand is lower than the elbow
Note: elbow should be more extended if the tone is low, and more flexed if high tone is present.
154
UE Function WB Sequence:
Involved Arm:
forearm
-Forearm: pronated
155
UE Function WB Sequence:
Involved Arm:
-Wrist:
Neutral in radial/ulnar deviation. Neutral to wrist extension (depending on amount of elbow flexion).
156
UE Function WB Sequence:
Involved Arm:
hand
-Hand: open on a WB surface. The arch of the hand should be preserved if possible.
157
UE Function WB Sequence:
Involved Arm:
```
Scapula
Shoulder
Elbow
Forearm
Wrist
Hand
```
- Scapula: stable against the thorax in slight abDuction and upward rotation
- Shoulder: humerus is away from the trunk in slight flexion, aBduction, and lateral rotation (elbow crease is forward)
- Elbow: between 90 degrees of flexion and complete extension so that the hand is lower than the elbow
- Forearm: pronated
- Wrist: Neutral in radial/ulnar deviation. Neutral to wrist extension (depending on amount of elbow flexion).
- Hand: open on a WB surface. The arch of the hand should be preserved if possible.
158
Elbow should be more ______ if the tone is low, and more _____ if high tone is present.
elbow should be more extended if the tone is low, and more flexed if high tone is present.
159
UE: Key points of control
One hand input dorsally on the trunk, and the other hand either on the dorsal humerus and ulna or at the wrist and hand
If patient doesn't need direct input to trunk both hands can be used to facilitate at the distal key points (humerus, ulna, wrist, and hand)
All pressures must be light and carefully graded, especially at the distal key points in the UE
160
UE:
WB
Begin with isometric contraction-> then eccentric -> then concentric
Need to monitor the whole body for changes in pressure and tone
Should incorporate head and eye movements
If possible begin with unilateral and then move to bilateral patterns
Progress from stable surface to less stable surface, with progressively more humeral elevation (need to maintain good alignment and optimum alignment of the thorax and scapula)
Begin with forward weight bearing, progress to posterior weight bearing if appropriate (start gentle respect pain and discomfort)
--There will be cervical spine tightness as well, be careful of pre-existing shoulder, back, or cervical spine pathology
Progress toward more upright postures, vary WB surface/ step standing at various heights, for a higher level person consider climbing/ four point, use of the UE in balance reactions, modified pushups at various angles
--Be very careful of alignment, safety and set up!
161
UE: contraction progressions
Begin with isometric contraction-> then eccentric -> then concentric
162
UE:
what should body be monitored for
Need to monitor the whole body for changes in pressure and tone
163
UE
what movements should be incorporated?
Should incorporate head and eye movements
164
UE
progression: uni/bilateral patterns
If possible begin with unilateral and then move to bilateral patterns
165
UE
progression surfaces
Progress from stable surface to less stable surface, with progressively more humeral elevation
(need to maintain good alignment and optimum alignment of the thorax and scapula)
166
UE:
WB progression
Begin with forward weight bearing,
progress to posterior weight bearing if appropriate (start gentle respect pain and discomfort)
----There will be cervical spine tightness as well, be careful of pre-existing shoulder, back, or cervical spine pathology
167
UE:
progression
posture, surface, height, use of UE
Progress toward more upright postures,
vary WB surface/ step standing at various heights,
or a higher level person consider climbing/ four point,
use of the UE in balance reactions, modified pushups at various angles
Be very careful of alignment, safety and set up!
168
Opening the High-Toned Hand:
Points of Contact that are Usually Safe:
1) The borders of the hand:
- -The hypothenar eminence (the ---shaft of the 5th metacarpal)
- -The heads of the metacarpals
- -The shafts of the 1st metacarpal
2) The palmar surfaces of the fingers, with care
3) Any place on the dorm except the thinner web space
169
Opening the High-Toned Hand:
Points of contact to avoid:
1) the center of the palm of the hand
2) the thenar eminence and muscle bellies
3) the thenar web: dorsal and ventral surfaces
170
Principles: opening high toned hand
| 5
1) Open the hand from distal to proximal. Extend the wrist last.
2) Extend the wrist last, but get and maintain neutral (or more neutral wrist deviation throughout)
3) The thumb out of the palm into radial abduction is key—movement from the CMC joint, not hyperextension at the MP joint
4) spread between the metacarpals (abduction) is key
5) Avoid MP hyper-extension a little short of neutral, especially of the second and third fingers is fine
171
UE
Weight Bearing:
1) UE and Gait: WB on a walker, platform walker, modified handle-OT can be helpful to collaborate. sue of shopping cart or NDT pole can also be helpful as WB surface.
2) Want to encourage the arm to be down and away from the body when walking if possible.
- ----Having the hand resting on a surface and pushing helps with this.
172
UE Impact on Gait:
Limiting Conditions:
volunteer for: mock up pelvic retraction, wear of a sling (with arm extended, and flexed) bracing…
Tools that can be helpful : use of a bolster/ ball/ peanut / egg/ disc / wedge both for sitting and as a WB surface with different properties, use of a bedside (or other) table, counter, space, inclined surface, bar stool or chair, cleaning a table or other surface: closed chain functional activity, can squirt bottle or do dry wipe, hi-lo mat for changing sitting height to progress towards upright
173
Progression of UE Activities:
3
1) Hand to head (start with chin-work your way up to top or back of head) with GH external rotation (need sufficient thoracic extension to avoid shoulder impingement)
2) Use of breath and soft tissue work on the ribcage
3) With elbow supported working on external rotation of the shoulder using rotator cuff musculature
174
Constraint Induced Movement Therapy
Concentrated, repetitive practice of functional activities using the more affected upper extremity in post-CVA patients
175
Evidence of neuroplasticity as it relates to motor function
main effect in doing this treatment is changing the wiring in the brain, the organization in the brain, there are studies showing what occurs in the motor and sensory cortex
main effect in doing this treatment is changing the wiring in the brain, the organization in the brain, there are studies showing what occurs in the motor and sensory cortex
176
Neuroplasticity:
what changes
the ability of synapses to change as circumstances require
177
What does the size of cortical representation of a body part depends on?
The size of cortical representation of a body part depends on the amount of use of that part
178
Cortical Mapping:
What does the degree that dermatomes on the skin have overlap depend on?
Dermatomes on the skin have cortical receptive fields that slightly overlap
Degree of overlap determines the degree of fine tactile discrimination
179
CIMT:
| How we measure cortical reorganization?
PET Scan
MRI
Transcranial Magnetic Stimulation
180
CIMT:
| What is the potential for cortical reorganization?
Rigidity of anatomical cortical mapping has been disproved
The brain is far more plastic than previously believed
The potential for cortical reorganization is great!
181
CIMT:
Why may extensive functional reorganization of the cortex be long lasting due to?
(ie hand)
(5)
1. Changed sensory experience
2. Performance of the hand
3. Local peripheral nerve injury—if no sensory input coming up the cord, i.e. amputation the sensory areas for that extremity will shrink due to not getting the input
4. Separation of syndactylies
5. UE slings
182
CIMT:
| Extensive use of finger can result in ____
Extensive use of finger can result in enlargement of projection ares of the brain
183
CIMT:
CNS Plasticity:
What is plastic
4
1. Synapse Plasticity:
- --Increased or decreased SENSITIVITY
- ---Increased or decreased actual NUMBER
2. Cortical Plasticity: Change in PROPERTIES of CORTICAL NEURONS
3. Cortical plasticity can be induced by changes in NEURAL ACTIVITY from the PERIPHERY
4. These changes are ACTIVITY DEPENDENT
184
CIMT:
| Neuroplasticity
1) Rapid, activity-dependent changes may reflect inhibitory or facility modifications in synaptic functions
2) Long standing deafferentation (amputation, nerve injury) result in loss of nerve axons (degeneration)
3) Cortical receptive field shifts can be detected within seconds of peripheral sensory deafferentation
185
CIMT:
| What type of changes can be caused by Rapid, activity-dependent changes ?
Rapid, activity-dependent changes may reflect inhibitory or facility modifications in synaptic functions
186
CIMT:
| What can long standing deafferentation (amputation, nerve injury) result in?
Long standing deafferentation (amputation, nerve injury) result in loss of NERVE AXONS (DEGENERATION)
187
CIMT:
| When can cortical receptive field shifts be detected?
Cortical receptive field shifts can be detected within seconds of peripheral sensory deafferentation
188
CIMT:
Proof of Activity Dependent Reorganization: Motor Cortex:
Behavior training of monkeys and squirrels
Task requiring skilled use of digits--Corresponding digit representation in motor cortex expanded
Reversible (if it is not continued long enough, the brain reverts back, it will continue once learned)
Cortical areas surrounding lesion began to participate in hand function
189
CIMT:
Use - dependent Cortical reorganization:
What the study showed with active use of specific fingers, new sensory experiences in the hand :
Active use of specific fingers, new sensory experiences in the hand --> functional reorganization of the somatosensory cortex
Maintained contact with rotating disc for 10-15 seconds: sustained cutaneous stimulation of on distal phalanx in order to obtain food-->
enlarged cortical area represented by stimulated finger compared to control distal phalanx
190
CIMT:
Cortical Representation can be Facilitated with use:
What happened with braille readers?
Increased MOTOR and SENSORY CORTICAL REPRESENTATION of index fingers in blind braille readers
Use must be ACTIVE, not by passive stimulation of the finger by braille reading device
ATTENTION to task is very important for optimal improvement
Patient needs to be able to attend to the task: ATTENTION IS VERY IMPORTANT FOR OPTIMAL IMPROVEMENT
191
CIMT:
Cortical Representation can be Facilitated with use:
What factors must be present? (2)
Use must be ACTIVE, not by passive stimulation of the finger by braille reading device
ATTENTION to task is very important for optimal improvement
192
CIMT:
Use-dependent Cortical Reorganization:
Can tactile function worsen with certain forms of sensory stimulation?
give example
Tactile function CAN also worsen with certain forms of sensory stimulation.
(ex distorted sensation and motor function after prolonged use of VIBRATORY HAND TOOLS)
Overuse can lead to negative changes occurring in the patient —negative effect
193
CIMT:
| Use-dependent Cortical Reorganization: —negative effect
Overuse can lead to negative changes occurring in the patient —negative effect
194
CIMT:
What happened in cortical representation of hands of string musicians?
What is strength of cortical reorganization correlated to?
What is cortical representation of the digits a function of?
Increased cortical representation of the hand of string musicians
Strength of Cortical reorganization is correlated to the age at which string musicians begin to play
Cortical representation of the digits expands as a function of PROLONGED, HIGH FREQUENCY frequency PRACTICE
195
CIMT:
Cortical Reorganization
The study that used transcranial magnetic stimulation to map the size of MOTOR CORTEX corresponding to the APB muscle in post CVA patients--what did it find?
Comparing pre and post CIMT, there was almost a 100% INCREASE in area able to produce a MUSCLE TWITCH, which extended BEYOND PRIMARY MOTOR CORTEX
196
CIMT:
| Negative Effects of Frequent Stereotyped Finger Use:
Dystonias
(writers cramp, focal hand dystonia in musicians)
motor areas for hand start to OVERLAP so any stimuli signals more motor output and that is where the dystonia, control training of less specific activity to go back to baseline
overuse issue because lead to these overlaps
Capacity to perform task declines over time, with difficulty of hand movements
Overuse can be detrimental
197
CIMT:
| What is dystonia?
Writers cramp, focal hand dystonia in musicians
Capacity to perform task declines over time, with difficulty of hand movements
Overuse can be detrimental
198
CIMT:
| An example where overuse can be detrimental
Writers cramp, focal hand dystonia in musicians
Capacity to perform task declines over time, with difficulty of hand movements
Overuse can be detrimental
199
CIMT:
In what environment should sensory re-education take place?
What will produce the most rapid changes?
Sensory re-education should be carried out in a POSITIVE environment -->reach into and manipulate objects to relearn and retrain how to interpret this sensory image
The practice setting in which the patient is CONTINUALLY REWARDED for correct performance trials will generate the most rapid changes
200
CIMT:
| Are passive unattended or occasionally attended exercises of value?
Passive unattended or occasionally attended exercises are of limited value to produce cortical changes
201
Why is it important in CIMT to have important training exercise?
The more important the training exercise, the more powerful its consequences
meaningful to the patient
202
How should feedback be implemented in CIMT?
The more feedback the subject gets, relevant to correct performance, the faster cortical changes will occur
MORE FEEDBACK
203
CIMT: what will get most rapid changes?
The practice setting in which the patient is CONTINUALLY REWARDED for correct performance trials will generate the most rapid changes
204
CIMT: what is shaping?
Behavioral training technique
205
CIMT:
Shaping: what is the strategy?
(6)
1. Behavioral training technique
2. Desired motor or behavioral objective is approached by successive small steps
start with a shorter step before going to a higher step
3. Explicit Feedback provided about the smallest improvement (knowledge of results feedback)
4. Provide lots of positive feedback, de-emphasize negative feedback
5. Relate shaping task to functional skills
functional tasks
6. Can use assisted movement with lower functioning patient
to get the normal movement feel, sensory feedback, motor training of the movement itself
note: we let them rest because fatigue will affect the performance
206
CIMT: What type of steps are taken when shaping?
Desired motor or behavioral objective is approached by successive small steps
start with a shorter step before going to a higher step
207
CIMT:
| Do we want implicit or explicit feedback when shaping?
EXPLICIT Feedback provided about the smallest improvement (knowledge of results feedback)
208
CIMT:
| Do we want positive or negative feedback when shaping?
Provide lots of positive feedback, de-emphasize negative feedback
209
CIMT
how do we make shaping relevant for the patient?
Relate shaping task to functional skills
210
CIMT
how do we adapt shaping for lower functioning patients?
Can use assisted movement with lower functioning patient
to get the normal movement feel, sensory feedback, motor training of the movement itself
211
CIMT
how should task PRACTICE be implemented?
****this is diff than shaping****
1. no explicit training (not specific feedback, practice a functional task receptively)
2. Functional Task used
3. Limited Feedback provided
4. Goal: USE OF LIMB
212
CIMT: Two Independent but linked mechanisms for CIMT (2)?
1) Overcoming learned nonuse-reveres the mindset of dysfunction
(experience tells the patient the arm is not working, this approach will show what this arm can do)
2: Cortical reorganization can occur with focused training: increased limb use
213
Overcoming learned nonuse
mechanism for CIMT
Overcoming learned nonuse-reveres the mindset of dysfunction
(experience tells the patient the arm is not working, this approach will show what this arm can do)
214
Cortical reorganization can occur with focused training: increased limb use
mechanism for CIMT
Cortical reorganization can occur with focused training: increased limb use
215
Two Independent but linked mechanisms for CIMT (2)?
1) Overcoming learned nonuse
| 2) Cortical reorganization can occur with focused training
216
Who developed CIMT?
Edward Taub
did his research on MONKEYS
Behavioral neuroscience
Monkey deafferentation research
Work picked up by Steven Wolf
Based on theories of LEARNED NONUSE (conditioned suppression of movement) and USE DEPENDENT CORTICAL REORGANIZATION
217
CIMT in Therapy and Stroke /TBI: what is the common denominator?
Common denominator: REPETITIVE, CONCENTRATED practice
Most promising evidence that motor recovery can be facilitated
Has evidence-based demonstration of therapeutic effectiveness
218
CIMT
common characteristics:
CI Therapy - Summary:
variety of therapies
common characteristics:
1) concentrated repeated use of the weaker arm.
2) Use at least 90% of each day for two weeks.
3) Massed practice (6 hours/day)
4) Less involved extremity is mitted (not use the good side)
219
**Optimizing functional Carryover**
What type of practice? Blocked or random?
Patients have more active learning in random practice. With blocked practice the initial outcome is better, but retention is better with RANDOM practice.
variability in practice increases the applicability or generalizability
220
What type of practice? Blocked or random?
What has better initial outcome?
Patients have more active learning in random practice. With BLOCKED practice the initial outcome is better, but retention is better with RANDOM practice.
221
What type of practice? Blocked or random?
What does patient have more active learning?
Patients have more active learning in random practice. With BLOCKED practice the initial outcome is better, but retention is better with RANDOM practice.
222
What type of practice? Blocked or random?
What has better retention?
Patients have more active learning in random practice. With BLOCKED practice the initial outcome is better, but retention is better with RANDOM practice.
223
What is Blocked practice?
repeat the activity over and over
224
What is random practice?
randomly doing one activity and then something completely different, cannot predict what will be asked to do next
225
CIMT
| What finger and wrist movements do you need to have?
10 degrees of wrist extension—active
10 degrees of thumb abduction
10 degrees of extension at 2 digits
50% of all stroke patients met this criteria --More recent studies have resulted in making improvement in lower functioning patients
226
CIMT
How much wrist extension do you need?
10 degrees of wrist extension—active
227
CIMT
How much thumb abduction do you need?
10 degrees of thumb abduction
228
CIMT
How much digit extension do you need?
10 degrees of extension at 2 digits
229
Study on bilateral movement training and stroke motor recovery progress: a structured review and meta analysis:
bilateral training effect on motor ability after stroke
Tailwind device was the bilateral arm trainer with Rhythmic Auditory Cueing (BATRAC) working on proximal muscle groups before distal muscle groups, active by the patient
Patients did better in a combined treatment working proximally and then working the hand rather than just reaching with assisted hand function
230
CIMT
1. what type of therapies
2. common characteristic about how often to use the weaker arm
3. what arm is mitted
1. variety of therapies
2. concentrated repeated use of weaker arm, use at least 90% of each day for 2 weeks
massed practice: 6 hours/day
3 less involved is mitted
231
CIMT
What kind of practice is needed? (4)
What should be avoided?
What kind of feedback?
ACTIVE
REPEATED
TASK SPECIFIC
Massed practice bilaterally
Avoid stressing CNS early in acute care
Significant feedback and encouragement
232
CIMT: Inclusion Criteria for constraint induced therapy
| 2
(forced use for cortical reorganization, working on improvement proximally and not only the overall task):
1) cognition intact (be focused on activity and it needs to be meaningful to them)
2) some active wrist and finger extension
233
CIMT:
| Massed practice: how much?
5-6 hours/day (weeks) or less intense for longer durations (months)
Restrained uninvolved UE 5-6 hours/day
Consider massed practice bilaterally
234
CIMT: what kind of practice is needed?
ACTIVE, REPEATED, TASK SPECIFIC practice is critical
Consider massed practice bilaterally
235
Why avoid stressing the CNS too early in acute care?
Don't want too much intense when trying to heal from the stroke-challenging the metabolic needs of the brain
236
What did 1 year follow show with and without use of a mitt on unaffected UE?
1 year follow up shows no difference with or without use of a mitt on unaffected UE (—eventually getting to some sort of functional level but maintaining those gains)
237
What is focal hand dystonia
Manual incoordination due to extensive forceful use of 1 or 2 digits
238
How is focal hand dystonia cortical?
Cortical problem:
neuro-imaging demonstrates use dependent OVERLAPPING (smearing) of representation of CORTICAL AREAS of 2 digits
(in dystonia one one area is firing so are other areas, an overactivity of muscles)
239
How to treat focal hand dystonia in german musicians
Germany: 10 musicians —RESTRAINED ALL DIGITS EXCEPT THE ONS WITH DYSTONIA:
control the use of the affected hand to tone down the activity in the muscles
make it more purposeful but finer recruitment of muscles
a lot of individuals with improvements were reorganizing CNS for less activity for more discrimination between the areas of the motor cortex of the hand
240
How to treat focal hand dystonia
restrain all digits EXCEPT for the dystonic ones
241
Future of CIMT
--Lower functioning subjects
--Subacute and acute
--Different diagnostic groups
CP
TBI
SCI
---LE Intervention
242
CIMT
how much practice?
Random or blocked?
What does patient need to do?
How much repetition?
What types of scheduling
What kind of compliance?
Massed practice is critical —need to do a lot
Random is better than blocked practice,
patient must be able to be motivated and to focus on the task,
enough repetition for CNS changes to occur
Innovative scheduling is needed
Patient compliance is also critical
243
Phantom Limb Pain Phenomenon :
mirror between legs and asked to work sound leg, pain from amputated leg went away.
Can use in CRPS, arthritic pain, stroke pain.
Practice with the sound side and see the reflection onto the amputated/painful side.
244
Conditions where can use mirror therapy
CRPS
arthritic pain
stroke pain
245
What side practice on in mirror therapy
Practice with the sound side and see the reflection onto the amputated/painful side.
246
3 main components of mirror therapy
1) Visual input (vs somatosensory)
visual input is substituted for somatosensory input
2) Mirror in mid-sagittal plane - reflecting the intact extremity as if it were the involved extremity
3) Movement of the intact extremity will look like bilateral movement
247
What does visual input substitute for in mirror therapy?
```
Visual input (vs somatosensory)
visual input is substituted for somatosensory input
```
248
In what plane is the mirror during mirror therapy?
Mirror in mid-sagittal plane - reflecting the intact extremity as if it were the involved extremity
249
What is the basis for mirror therapy?
Neurological basis = “Mirror-neuron system”:
motor neuron system has ability to learn by mirroring the actions of someone else,
this is how animals learn from other animals, and this carries over into
250
Mirror therapy: Cortical neurons that are activated while _____ can also be activated by _________
Cortical neurons that are activated while moving can also be activated by watching a movement
251
Mirror therapy:
Primitive means of learning by imitation of the actions of another like animal, person.
BABIES exhibit this ability: make a face at the baby and the baby will also do it baby learn to smile from parents smiling at baby
AUTISM – “broken mirror” hypothesis dont make the eye contact and use that interaction, maybe this is where the limitation is coming from
252
Mirror therapy: what is found in healthy individuals in the motor cortex when mirror used?
healthy individuals show that the motor cortex activity occurs with mirror visualization
—motor cortex that would power the side not in the image is activating when did a left to right task
play better after watch an athlete play—mirroring
253
Is mirror therapy only based on the vision of movement?
Imitation of movement can’t be the sole therapy – need VISION, PROPRIOCEPTION and MOTOR COMMANDS
254
MT early after stroke is a promising method to improve what?
** MT early after stroke is a promising method to improve SENSORY and ATTENTIONAL deficits and to support MOTOR recovery in a DISTAL plegic limb.**
In the subgroup of 25 patients with distal plegia at the beginning of the therapy, mirror therapy patients regained more DISTAL FUNCTION than control patients.
Furthermore, across all patients, MT improved recovery of surface sensibility.
Neither of these effects depended on the side of the lesioned hemisphere. MT stimulated recovery from hemineglect.
255
Mirror Visual Feedback =
Mirror Visual Feedback
= “movement of one limb is perceived as movement of the other limb..” Deconinck, et al. (2014).
256
Mirror therapy
Areas of the brain fired when patient performed these activities:
it is part of a big network, not only a mirror neuron system:
1. Superior Temporal Gyrus
2. Pre-motor Cortex
3. Ipsilateral primary motor cortex (M1)
4. Integration with attention (precuneus area)
5. Mirror neuron system may connect the perceptual and the motor areas
257
Facilitation Theory:
started with Reflex Therapy and incorporated Hierarchical Theory
Started with reflex theory:
- Reflex Theory:
- ---Tap hypertonic muscle get exaggerated stretch reflex after stroke
- ---Marie Foux to bend big toe gets withdrawal
Hierarchial Theory: the idea of progressing through stages to get to following stages
258
Motor Control Theory
Task Oriented: started with Motor Programming Theories and Systems Theory (Bernstein 1967) and progressed to Dynamic Action Theory and Ecological Theory
Motor programming and Systems Theory and how brain processes input to facilitate motor output
259
What theory based on Intact and decerebrate spinalized cats, monkeys, and dogs
Facilitation Theory: sherrington
Yielded evidence of primitive reflexes where an afferent stimulus could yield a motor response
exaggerated responses to these stimuli and movement patterns that stimulated some of these primitive reflexes
facilitate recovery using an outside to inside approach:
Tapping muscles to make them work,
ATNR to facilitate extension on one side, using these to our advantage
Outside: PT does to patient
Inside: patient executes movement
260
Role of PT and patient in outside inside approach
PT is facilitator and patient is active but more reliant on the therapist in the outside to inside approach
261
Bobath: Premise of theory
Bobath: NDT: Neurological Treatment: (pediatric and adult):
basic premise: synergy is undesirable: facilitating normal postural responses (righting and equilibrium responses) is needed to improve function.
262
Kabat/Knott/Voss: Prioprioceptive Neurolomuscular Facilitation (PNF):
Premise of theory
basic premise: training based on functional synergies (patterns) to facilitate normal movement and inhibit abnormal movement
use proprioceptors to facilitation neuromuscular system
use sensory system to get motor response
move in functional synergies and use sensory stimuli to get motor response
approximation, traction, resistance to get spindle, quick stretch to get myotatic reflex, quiet voice or loud voice for certain responses
263
Dynamic Systems Theories:
“Change occurs because one control parameter or variable reaches a critical value which causes a change in the entire system”
264
Generalized Motor Program Theory:
Motor system stores programs that abstractly represent movement learned in specific context (dont need sensory: doesnt pick up ball and still gets ready to throw it)
Motor plans that are individual and context specific
Not dependent on peripheral sensory signals for execution
Sensory systems are important for error detection and then changing a movement
Incorporates anticipatory postural adjustments
Motor system has programs that represent learned motor paths—these tasks then become individualized and context specific so that when I am in that environment the program is automatic
265
Neuronal Group Selection Theory:
Brain development—strongly interconnected groups of neurons that are strengthened by experience of moving. These groups become activated in response to task conditions
Central Pattern Generator for Gait: once gait is initiated not every little step need to be monitored by the cortex but can be on the spinal cord level and do not have to think about it and worry about where should I put this foot, it is more automatic because a central pattern generator of the cortex feeds to a lesser area of the CNS: a reverberating circuit: less like a program, more like hardwiring
266
Central Pattern Generator for Gait:
once gait is initiated not every little step need to be monitored by the cortex but can be on the spinal cord level and do not have to think about it and worry about where should I put this foot, it is more automatic because a central pattern generator of the cortex feeds to a lesser area of the CNS: a reverberating circuit: less like a program, more like hardwiring
267
Carr and Shepherd: Motor Relearning Program for Stroke:
basic principle: patients must actively be involved in relearning movements based on the biomechanical necessities of the tasks and on their refinement of motor output
268
Hypotheses: Learning or Relearning Movement Patterns Requires
An appropriate environment is needed for learning
Continual correct practice—becomes more ingrained
Appropriate feedback geared to the stage of motor learning
Integration of simple and complex movements to achieve ADL goals
Transfer training from the therapy environment to the real world
Cognitive element to learning new motor skills cannot assume patients will use a new pattern just because it is more efficient they must understand the rationale for the change
PT is a trainer: serves as a resource for the learning process but PT not needed for the movement to occur—help make corrections but not needed for the movement to occur
269
BWSTT:
Physiological Necessities for Gait:
1. Biomechanics
Appropriate joint ROM
Strength
Appropriate timing
2. Neuromuscular Control
- --Cortical Level: initiate gait, redirect it
- --Spinal cord level-spinal cord generator yielding automaticity and reproducibility
- --Peripheral level
- --Balance, Strength, and Coordination
3. Cardiovascular Stanima
270
BWSTT: Biomechanics needed for gait (3)
1) Appropriate joint ROM
2) Strength
3) Appropriate timing
271
BWSTT: Neuromuscular control needed for gait (4)
1) Cortical Level: initiate gait, redirect it
2) Spinal cord level-spinal cord generator yielding automaticity and reproducibility
3) Peripheral level
4) Balance, Strength, and Coordination
272
BWSTT: Neurological Disorders: Gait Deficits
| Where can they occur?
5
---Any part of the neuromotor pathways affecting gait can malfunction and lead to abnormalities
---CNS
1) Higher centers: dyscontrol over spinal outflow (higher centers do not have control over lower centers: difficulty initiating and loss of strength)
Tone problems, difficulty initiating the movement, decreased strength
2) Basal Ganglia: modulation of movement
3) Cerebellum: balance and coordination
4) Spinal Cord Lesion: weakness, tone issues
273
BWSTT: Neurological Disorders: Gait Deficits
CNS
Higher centers: dyscontrol over spinal outflow
(higher centers do not have control over lower centers: difficulty initiating and loss of strength)
Tone problems, difficulty initiating the movement, decreased strength
274
BWSTT:
Basal ganglia
modulation of movement
275
BWSTT:
cerebellum
balance and coordination
276
BWSTT:
SC lesion
weakness, tone issues
277
BWSTT: What components to address in Neurological Disorders: Gait Deficits? (5)
1 . Strength
2. Coordination
3. ROM
4. Postural Stability
5. Dynamic balance control
278
BWSTT: What point best motor recovery post stroke?
6 week window where recovery curve has steep slope
Window for best motor learning for 6 weeks post stroke
(Recovery still occurs for protracted period with curve showing a lower slope
Outcomes appear to plateau and patient loses interest, has cardiovascular de-conditioning
)
279
Central pattern generator: Sherrington
spinalized cats step when exposed to stimulus/supported over treadmill
280
Without having upper motor neuron control, can there be a stepping response on a treadmill?
Grillner/Dubuc: decorticate cats spontaneously initiate locomotion, difficult to identify any clear deficit in motor behavior (without having upper motor neuron control, can have a stepping response on a treadmill)
281
Central Pattern Generator:
What is it?
Does it need descending control?
Can we change the central pattern generator in case of CNS issue?
Spinal processes capable of producing rhythmic control of one limb
With our without descending control
Adaptable/plastic: can learn specific tasks
by using these devices ie BWSTT: we can change the central pattern generator in cases of central nervous system problems
282
Does central pattern generator have specificity?
Hodgson: Training spinalized cats to stand diminishes their potential to walk
when train them to stand, they cannot walk: there is specificity to the circuitry
283
Do humans have Central Pattern Generator or is it related to muscle stretch?
reported locomotor like rhythmic EMG activity during passive training of clinically complete SCI patients
Modulated by LIMB LOADING and NOT muscle stretch
It is not purely reflex: there was EMG activity in complete SCI that could be proportionally to amount limb loaded and not proportional to the stretch on the muscle
284
BWSTT
| Treatment Rational: (9)
1) Bio-mechanical environment
2) Rhythmic coordinated movement
do it over and over
3) Stimulate CPG (central pattern generator)
4) Reach brainstem with partially intact pathways to activate higher centers
5) Postural stability: to help with postural stability
6) Goal oriented: to walk on ground in the way you walk on the treadmill
7) Task-specific
8) Intensive
9) **Normal afference—These are critical components: You MUST have these when practicing
Mid stance limb loading
Terminal stance: hip extension
285
BWSTT: What kind of environment?
Bio-mechanical environment
286
BWSTT: What kind of movement?
Rhythmic coordinated movement
| do it over and over
287
BWSTT: what do we try to stimulate?
Stimulate CPG (central pattern generator)
288
BWSTT: what part of the brain do we try to reach?
Reach brainstem with partially intact pathways to activate higher centers
289
Does BWSTT adress posture?
Postural stability: to help with postural stability
290
How is BWSTT goal oriented?
Goal oriented: to walk on ground in the way you walk on the treadmill
291
is BWSTT task specific?
Task-specific
292
WHAT COMPONENTS MUST BE PRESENT IN BWSTT?!?!
**Normal afference—These are critical components: You MUST have these when practicing
1) Mid stance limb loading
2) Terminal stance: hip extension
293
WHAT COMPONENTS MUST BE PRESENT IN BWSTT?!?!
1) Mid stance limb loading
| 2) Terminal stance: hip extension
294
WHAT COMPONENTS MUST BE PRESENT IN BWSTT?!?!
1-Unilateral loading of limb at midstance
2-Hip extension at terminal stance (push off)
295
BWSTT: how is patient progressed?
Reduce support as patient progresses : more patient body weight, less support
(ie can start at 30% BW taken up by the machine at .7-1.1 m/s)
296
What populations have been found to benefit from BWSTT?
```
Stroke
SCI
TBI: walking speeds improved and balance
CP: relative improvements in GMFM scores
Downs Syndrome: benefited
```
297
Is BWSTT task specific?
- task specific training, task specific speeds
- therapist is cuing and controlling the legs—you dont have to hold the patient up but you do have to move the limb for the patient which is difficult to do , usually need to coordinate to have one on each leg and one helping the WS
298
BWSTT Allows therapist to:
| 10
1) Control WB
2) Manually assist limb placement
3) Control postural alignment (forward lean, backward lean)
3) Adjust for unilateral weakness
4) Facilitate proper gait pattern
5) Work on symmetry, weight shift
6) Facilitate hip extension
7) Observe/evaluate gait
8) Begin earlier GT
9) Teach use of AD
10) Work on vestibular responses
299
BWSTT Training Parameters:
1. Speed
2. Support
3. Assistance
Speed: from .1mph [slow]
Support 40% BWS (body weight support) and gradually progress to 0%
Assistance: from max progress to min
300
What speed start for BWSTT
Speed: from .1mph [slow]
301
What support given in BWSTT
Support 40% BWS (body weight support) and gradually progress to 0%
302
What assistance given in BWSTT?
Assistance: from max progress to min
303
What is BWSTT success dependent on?
*Patient motivation*, commitment
note set up takes a long time, needs to be budgeted in
note that there are stress injuries in PTs
because sitting facing side of patient so lumbar spine twisted-dont want a repetitive stress injury
304
BWSTT: Treadmill:
1. what speed?
2. treadmill design?
3. allow misteps?
1. Very slow speeds
Small increments of increase in speed
able to maintain speed without slowing/stalling
2. long enough to allow for completion of normal stride
wide enough to accommodate patients BOS
comfortable for therapist facilitation
Handrails: may interfere with balance
3. allow misteps
305
BWSTT: Unloading System:
| 5
1. ) counterweights
2. ) Springs/cables
3. ) Adjustable straps
4. ) 1-point vs 2-point system
5. ) width
306
BWSTT Harness
| 6
1) Pelvic control
2) Upper body postural support
3) Promote upright posture
4) Tight enough to prevent slippage
5) Comfort
6) Easy on and off
307
BWSTT--why PT needs to be careful
safety issue
body mechanics
repetitive stress
308
BWSTT Protocol
| 5
1. BWS
2. Speed of treadmill
3. Length of Session
4. Frequency
5. Duration
309
LEAPS: Locomotor Experience Applied Post-Stroke:
Clinically: in order to determine gait improvement it needs to change by at least 0.16 m/second
310
Clinically: in order to determine gait improvement it needs to change by at least _____ m/second
0.16 m/second
311
What is best practice to increase walking speed?
Best practice:to increase walking speed use BWSTT because it can happen in training period and be maintained for up to 6 months afterwards
312
benefit of lokomat
1. Provide BWS
2. Allow faster speeds
3. Allow therapist to have hands free
4. more precision in how robot delivers
biomechanical necessities
5. Training protocol can increase cardiovascular endurance
* Studies show lokomat and BWSTT is the same effect
313
What is Pusher Syndrome?
strong pushing toward the weak side ,
**resistance to passive corrections of posture** —to the vertical upright: they push back
