Recognizing & Examining Impairments in Individuals with Neuromuscular Involvement

- Hyperactive stretch reflex (unless cerebellar involvement)

- Presence of primitive/developmental reflexes

what are 2 abnormal reflexes seen with CNS damage?

Myoclonic jerk

what is an example of a phasic abnormal posturing or bursts of activity in response to various sensory stimuli seen with central nervous system damage?

Sustained abnormal posture

what is an example of a tonic abnormal posturing or bursts of activity in response to various sensory stimuli seen with central nervous system damage?

association reactions

defined as when involuntary movement occurs in one part of the body when voluntary movement attempted at another part

- Synergy patterns

- Co-activation patterns (agonist and antagonist)

what do voluntary stereotypic pathologic movements seen with central nervous system damage entail (2 things)

decreased (paresis)

Characteristics of Major Motor Control Disorders

• UMN Lesion (corticospinal) effect on muscle strength?

variable atrophy

Characteristics of Major Motor Control Disorders

• UMN Lesion (corticospinal) effect on muscle bulk?

association reactions

Characteristics of Major Motor Control Disorders

• UMN Lesion (corticospinal) effect on involuntary muscle contraction?

velocity-dependent increased (spasticity)

Characteristics of Major Motor Control Disorders

• UMN Lesion (corticospinal) effect on muscle tone?

decreased

Characteristics of Major Motor Control Disorders

• UMN Lesion (corticospinal) effect on movement speed and efficiency?

decreased or normal, depending on location of lesion

Characteristics of Major Motor Control Disorders

• UMN Lesion (corticospinal) effect on postural control?

- How far can the client move COG before loss of stability?

- What is the pattern of movement before loss of balance (LOB)?

- Shifting weight side to side, forward and backwards, reaching, scooting

what are key areas examined when using a task-oriented approach to test limits of stability - sitting and standing

- Quiet steady state (static)

- Apply externally generated perturbations to examine reactive balance (right, left, forward and backwards)

- Standing reaching: limits of stability and anticipatory balance

- Weight shift to unload leg or step: Limits of stability and anticipatory balance

- Standing with narrow base of support, feet together, tandem stance, single leg stance (Steady state with NBOS)

- Standing on compliant surface eyes open and/or eyes closed (sensory integration)

what are the parts of a Standing Balance Procedure

Describe if ankle, hip, or stepping strategies are used

what should we look for when applying externally generated perturbations to examine reactive balance (right, left, forward and backwards)

- Reaching forward, behind, and lateral

- If demonstrating poor volitional weight shifts, consider guiding pelvic motion to see if you can get trunk activation and better alignment

what are considerations for standing reaching: limits of stability and anticipatory balance testing

Somatosensory impairment

A patient with neurologic involvement is able to maintain quiet standing independently with eyes open, but demonstrates significant instability reliance on hip strategy when the eyes are closed. Which impairment is most likely contributing to this finding?

Limits of stability and anticipatory postural control

A physical therapist documents the following during sitting balance assessment: "Patient maintained sitting at edge of bed independently for 2 minutes. During reaching outside the base of support, the patient appropriately activated contralateral trunk musculature to shift weight and prevent loss of balance." Which components of balance control is the therapist most directly describing?

motor units

Force depends on the number of _______ recruited, type of units, and discharge frequency

paresis

slight or partial paralysis

Plegia

significant or full paralysis

unilaterally

Paresis usually occurs _____ (hemiparesis)

- STS

- squat

- heel raises

what are functional methods to measure strength (name 3)

spasticity

velocity-dependent resistance to muscle elongation

rigidity

non-velocity dependent resistance to muscle elongation

- Hyperactive stretch reflex

- Abnormal posturing of limbs

- Co-activation of antagonist muscle (Ex. Rectus femoris during pre-swing)

- Associated movements - spasticity occurs in one limb due to movement of another

- "Clasp knife": sudden, significant catch that "melts away" quickly

what are the different forms in which spasticity can present clinically

- Lead pipe - increased resistance to stretch due to rigidity

- Cogwheeling: rigidity superimposed with tremor (often felt with PD)

what are the different forms in which rigidity can present clinically

- Ashworth Scale or Modified Ashworth Scale

- Clonus with quick stretch

- Pendulum Drop Test (What does this tell you?)

- Surface EMG

types of Tone Assessment

grade 0

modified ashworth scale grading

• no increase in muscle tone

grade 1

modified ashworth scale grading

• slight increase in muscle tone, manifested by a slight catch and release or by minimal resistance at end of ROM when the affected part is moved in flexion or extension

grade 1+

modified ashworth scale grading

• slight increase in muscle tone, manifested by a catch, followed by min resistance throughout remainder of ROM

grade 2

modified ashworth scale grading

• more marked increase in muscle tone, passive movement difficult

grade 3

modified ashworth scale grading

• considerable increase in muscle tone, passive movement difficult

grade 4

modified ashworth scale grading

• affected part rigid in flexion or extension (takes a lot of force to move)

- Loss of ROM

- Loss of joint integrity

- Pain syndromes

- Disuse atrophy

what are types of Secondary Musculoskeletal Impairments

- increased tone in muscle groups

- chronic positioning or abnormal movements

what primary impairment does the secondary musculoskeletal Impairment of loss of ROM correlate to

- Chronic sitting results in hip flexor tightness

- Loss of flexibility due to imbalance of muscle activation

chronic positioning or abnormal movements can cause what kind of secondary ROM MSK impairments

- Ligament stress due to chronic knee hyperextension

- Shoulder subluxation due loss of rotator cuff activation

what are examples of secondary MSK impairments that result in loss of joint integrity

synergy

nervous system's ability to coordinate multiple muscles and joints as a single, functional unit to achieve a complex goal

appropriate sequence, timing, and force gradation of multiple muscles

what is needed for synergy to occur

Unintended Co-contraction of other muscle groups during volitional movement

What is the result of abnormal synergies associated with stroke primarily a motor control deficit

Proximal stabilization to isolate distal joints

__________________________________ is a common compensation to mitigate abnormal segmentation and loss of joint control

- Retraction and elevation of scapula

- External rotation and abduction of shoulder

- Flexion and supination of elbow

- Flexion of wrist and fingers

- Strong components are retraction of shoulder and elbow flexion

Abnormal Movement Synergies Associated with Stroke: Upper extremity flexor synergy

- Protraction and depression of scapula

- Adduction and internal rotation of shoulder

- Extension of elbow

- Pronation of forearm

- Flexion of fingers

- Strong components of shoulder adduction and internal rotation and elbow pronation

Abnormal Movement Synergies Associated with Stroke: Upper extremity extensor synergy

- Hip abduction, external rotation and flexion

- Knee flexion

- Ankle dorsiflexion and inversion

- Toe dorsiflexion

- Strong component is hip flexion

Abnormal Movement Synergies Associated with Stroke: Lower extremity flexor synergy

- Hip adduction, internal rotation and extension

- Knee extension

- Ankle plantar flexion and inversion

- Toe plantar flexion

- Strong components are knee extension, hip adduction, plantar flexion and inversion of ankle.

Abnormal Movement Synergies Associated with Stroke: Lower extremity extensor synergy

stage 1

Brunnstrom Stages of Motor Recovery

• Flaccidity (no movement, no tone)

stage 2

Brunnstrom Stages of Motor Recovery

• Spasticity developing

- Association reactions

- Gradual voluntary movements

- Voluntary movements are initiated in synergy

- < 1/3 of ROM

What does Brunnstrom Stages of Motor Recovery stage 2 entail

stage 3

Brunnstrom Stages of Motor Recovery

• Voluntary movements

- Can move limb through 1/3 ROM of synergy voluntary

- Max spasticity

What does Brunnstrom Stages of Motor Recovery stage 3 entail

stage 4

Brunnstrom Stages of Motor Recovery

• Voluntary movement

- Starting to move out of synergy

- Spasticity starts to decrease

What does Brunnstrom Stages of Motor Recovery stage 4 entail

stage 5

Brunnstrom Stages of Motor Recovery

• Synergies lose dominance

Movement is more out of synergy

What does Brunnstrom Stages of Motor Recovery stage 5 entail

stage 6

Brunnstrom Stages of Motor Recovery

• Isolated movement is available

- No spasticity is readily evident

- Spastic synergistic influence may come on with stress

- Coordination is near normal

What does Brunnstrom Stages of Motor Recovery stage 6 entail

stage 7

Brunnstrom Stages of Motor Recovery

• Normal motor function or restored normal function

- Speed

- Strength

- Coordination

What does Brunnstrom Stages of Motor Recovery stage 7 entail

flaccidity

Brunnstrom Stages of Motor Recovery: stage 1

- Recovery from hemiplegia occurs in a stereotyped sequence of events that begins with a period of _______ immediately following the acute episode.

- No movement of the limbs can be elicited

associated reactions

spasticity

Brunnstrom Stages of Motor Recovery: stage 2

- As recovery begins, the basic limb synergies or some of their components may appear as _________, or minimal voluntary movement responses may be present.

- At this time, ______ begins to develop.

full range

Spasticity

Brunnstrom Stages of Motor Recovery: stage 3

- Thereafter, the patient gains voluntary control of the movement synergies, although __________ of all synergy components does not necessarily develop.

- ________ has further increased and may become severe.

review

Brunnstrom Stages of Motor Recovery: stage 4

Some movement combinations that do not follow the paths of either synergy are mastered, first with difficulty, then with more ease, and spasticity begins to decline.

review

Brunnstrom Stages of Motor Recovery: stage 5

If progress continues, more difficult movement combinations are learned as the basic limb synergies lose their dominance over motor acts

joint movements; coordination

Brunnstrom Stages of Motor Recovery: stage 6

- With the disappearance of spasticity, individual _________ become possible and ______ approaches normal.

- From here on, as the last recovery step, normal motor function is restored, but this last stage is not achieved by all, for the recovery process can plateau at any stage.

Freezing

Festinating

Timing/Speed Impairments that can be seen in patients with PD

- _______ = difficulty initiating movement

- _______ = difficulty stopping movement

tremor

rhythmic back-and-forth or oscillating involuntary movement about a joint axis

dystonia

involuntary sustained or intermittent muscle contractions cause twisting and repetitive movements, abnormal postures, or both

chorea

• ongoing random-appearing sequence of one or more discrete involuntary movements or movement fragments

• Brief, fast, and "flow" from body segment to segment

athetosis

• Slow, continuous, involuntary writhing movement that prevents maintenance of stable posture

• Slower, typically hands/feet, and occurs in same body region

myoclonus

sequence of repeated, often non-rhythmic, brief shock-like jerks due to sudden involuntary contraction or relaxation of one or more muscles

- The movement is under voluntary control but joints are coupled

- Abnormal stroke synergies used in function

- Normal coupling of movements for walking or reaching

what does it mean when a movement is presented as a combination of voluntary/synergistic:  

- Movement is under voluntary control

- The person can move one joint in one direction at a time

what does it mean when a movement is presented as a combination of Voluntary/isolated:

- Movement occurs without conscious command

- RUE flexor synergy occurred as an association reaction during ambulation.

what does it mean when a movement is presented as a combination of Involuntary/synergistic:  

- Action Tremors

- Cervical dystonia

- Stretch Reflex

what does it mean when a movement is presented as a combination of Involuntary/isolated: