movement system dx for neuromuscular conditions

what are the 8 diagnoses?

1. movement pattern coordination deficit

2. force production deficit

3. fractionated movement deficit

4. postural vertical deficit

5. sensory selection and weighting deficit

6. sensory detection deficit

7. dysmetria

8. hypokinesia

what is the disregard or neglect modifier?

disregard is cant feel

neglect is cant percieve, ex is left sided neglect

what is the agitation modifier?

behavioral deficit (agitated, fidgeting, anger)

what do the confusion, decreased attention and memory loss modifiers lead to?

troubles retaining education

what is the apraxia modifier?

motor planning problem and trouble sequencing

what is the balance confidence modifier?

fear avoidance and self limitation

what is decreased dual tasking modifier?

struggle to do two things at one time, sensory OR motor

what is structural joint deformity modifier?

loss in ROM or postural change

can two diagnoses be assigned?

if multiple, equally impactful impairmentsw

what is force production deficit?

key impairment is weakness, and the range of severity affects the prognosis

two types: FPD with a good prognosis for recovery of strength, and FDP with a poor prognosis for the recovery of strength

is the health condition for FPD (force production deficit) CNS or PNS?

either!

what are the chief complaints of force production deficit?

tripping, fatigue, weak, buckling

what are key tests and signs for FPD?

• strength:

  • less than 3+ to 4/5 either focal or generalized

  • difficulty moving through full range against gravity

  • deterioration in ROM/speed of movement with repetition

  • patients with significant weakness will need varied levels of assistance (independent to dependent)

What are associated signs for FPD?

• fractionated movement

• normal to milde altered muscle tone

• normal to mild impaired sensation

• notable weakness=coordination deficits (slow but accurate)

• possible need for supportive structures

• postural control: in early stages of recovery, unable to sit or perhaps stand unsupported, would fall without support (BIG SPECTRUM)

what are the outcomes of FPD?

FPD GOOD: the more movement the earlier, the better the outlook

FPD POOR: not poor overall prognosis. poor likelihood of recovering the strength impairment, they can achieve independence and goals via compensation

What is the intervention focus for FPD GOOD?

restoration/remediation

what is the intervention focus for FPD POOR?

compensation

what is the key impairment for movement pattern coordination deficit?

mild coordination deficit

what are chief complaints of MPCD?

messy, falls, clumsy, unsteady, awkward (tend to be higher level of function)

what are key tests and signs for movement problem coordination deficit?

• postural responses are slow/inappropriate amplitude

• sit to stand

  • altered sequence or direction of movement components during execution (knee extension before hip extension, posterior rather than anterior translation of tibia over foot, ankle sway during termination)

• gait: variable foot placement/line of progression, slow and guarded steps

• reach/grasp: awkward/slow, difficulty adjusting grip during transport

  • difficulty with transitions as develop in age

what are the associated signs for Movement problem coordination deficit?

• little to no muscle weakness

• generally fractionated movement

• none to mild spasticity

• none to 2 on the modified ashworth

• none to mild sensory loss

• none to mild non-equilibrium coordination deficits

  • latency/sway, inappropriate amplitude of movement affecting balance

is the outcome for MPCD favorable?

yes! Independent with all things generally speaking w

what is the intervention focus for movement problem coordination disorder?

restoration and remediation

• limb use and refining movement strategy

• improving movement speed and amplitude

• improving coordination of anticipatory and reactive postural responses relative to balance demands

• generating consistency, flexibility, and efficiency of motor behavior during changing environmental demands

what is key impairment for dysmetria?

inability to grade forces appropriately for distance and speed of a task

what is the medical diagnosis of dysmetria?

most commonly those affecting the cerebellum (cerebellar stroke, SCA, TBI, MS, lesion)

what are the common chief complaints of dysmetria?

overshooting, clumsy, dyscoordination, cerebellum, wide BOS

what are key tests and signs of dysmetria?

non-equilibrium coordination: notable under or overshooting

abnormal rhythm and incoordination that DOES NOT IMPROVE with practice

able to move against gravity

WIDE BOS, excessive postural swar

what do people with dysmetria have the most difficulty with?

termination phase of movement because they overshoot

what are associated signs of dysmetria?

often needs UE support to sit safely if more severely impaired

wide BOS, high guard

variable foot placement

generally requires assistance

what is the outcome and intervention focus for dysmetria?

variable, but mostly compensation, slowing down, using ADs and orthotics

what is the key impairment of hypokinesia?

slowness in initiating and executing movement

may be associated with stopping of ongoing movement

what is the health condition for hypokinesia?

parkinsons disease

what are the chief complaints for hypokinesia?

slow, rigidity, unsteady, tremor, festination, shuffling, retropulsion, freezing

what are the key tests and signs of hypokinesia?

• able to move gainst graviting

• difficulty initiating movement

• delayed timing of postural adjustments

• lack of preparatory movments (not scooting or leaning forward), may use momentum

• assistance required especially with transitional movements

• retropulsion (LOB posteriorly)

• poor (delayed/absent) postural responses

• PD later in the diseas can develop freezing of gait or festination

what are the associated signs of hypokinesia?

• rigidity (increased muscle tone)

• non equilibrium coordination: undershoots target, slow reciprocal movement

• peds: delayed integration of early/primitive reflexes

what is the outcome for hypokinesia?

• variable but mostly compensation

  • TAKE BIG STEPS

  • slow turns

  • use ADs

what is the key impairment of fractionated movement deficit?

inability to fractionate movement

what is fractionate movement?

Ability to control independent movements of body parts for coordinated tasks.

what is the health condition of fractionated movement deficit?

it is ALWAYS related to the CNS (spasticity/tone)

what are the chief complaints of fractionated movement deficit?

stiff, contracture, rigid, slow, synergy

what are the key tests and signs of fractionated movement deficit (FMD)?

• non-fractionated movement: no dissociation of movement from one joint to the other

• unable to generate quick movements

• moderate to severe hyperexcitability

• Grade 3-4 on the modified ashworth scale

• SCALE scores of <5 for either LE would indicated FMD

• may exhibit abnormal reflexes (ATNR, STNR)

what are associated signs of FMD?

• associated reactions with efforts (involuntary limb draw)

• lacks dissociation of muscle groups during activitys, sterotypical pattern

• compensatory gait signs

• stiffness of gait

• scissoring

• ADs and AFO commonly needed

• reach limited, minimal hand movement in grasp

• assymmetrical postural control is frequent

• contractures

what is the outcome of FMD?

it depends on the underlying strength, however it TENDS TO BE POOR

what is the intervention for FMD?

compensation, patients DO NOT have the capacity to move normally, so dont expect improvements with cues to incorporate essentrial components

what is the key impairment for sensory selection and weighting deficit?

decreased ability to screen and attend to appropriate sensory inputs

what are the health conditions related to sensory selection and weighting deficit?

stroke, TBI, BPPV with postural instability, unilateral or bilateral vestibular hypofunction, sensory integration disorder, autism, rhett’s syndrome, pervasice developmental disorder, sensory processing disorder

what are the common chief complaints of sensory selection and weighting deficit?

dizziness, visual sensitivity, spinning, vertigo, weaving, sensory avoidance, unsteadiness

what are the key tests and signs of of sensory selection and weighting deficit?

• sitting/standing: increased sway, greater instability with head movement or changes in sensory conditions (eyes closed, compliant surface)

• standing: hip strategy used at inappropriate times

• gait: variable line of progression with walking, excessive lateral sway with turns, deviation with head turning, loss of balance, dizzy, worse with increased speed

• difficulty making transitions from one sensory environment to another

• postural resources may be delayed or exaggerated

• may improve with modification of sensory needs and practice

• symptoms with smooth purusit or saccadic eye movements

what are associated signs of sensory selection and weighting deficit?

• movement is fractionated and non-equilibrium coordination is intact

• may have positive vestibular tests

• sensation/sensory behavior

  • may show sins of gaze

  • may show signs of self stimulation behaviors such as rocking, spinning and banging

what is the outcome for sensory selection and weighting?

good! independent ambulation with no or mild deficits

what is the intervention focus of sensory selection and weighting deficit?

resorative!

what is the key impairment of sensory detection deficit?

lack of joint position sense or multi-sensory failure

what health conditions are associated with sensory detection deficit?

JPS, vision or bilateral vestibular loss

what are common chief complaints for sensory detection deficit?

dull, need vision, numb, unsteady

what are key tests and signs for sensory detection deficit?

• sensation: moderate to severe loss of JPS, mild or greater loss of JPS and touch sensation

• STS and step up: hyperextension of knees before hip extension during execution

• gait: increased BOS, variable foot placement, increased sway, inreased knee hyperextension, some improvement with visual guidance

• grasp/inhand manippulation: clumsy, some improvement with visual guidance

• needs postural support or has increased saway

what makes sensory detection deficit worse?

it is worse with eyes closed (or in low light environments) because they can no longer compensate with vision,

limited improvement with practice

what are associated signs with sensory detection deficit?

poor timing and coordination of movement, slow and clumsy, some improvement with visual guidance

what is the outcome for sensory detection disorder?

variable with compensation, allow compensation and device, dont walk on grass!

what is the key impairment of postural vertical deficit?

inaccurate perception of vertical orientation with resistance of correction of mass alignment

what is the health condition related with postural vertical deficit?

stroke

what is the chief complaint for postural vertical deficit?

falling, resisting, leaning, pusher

what are key tests and signs of postural vertical deficit?

• resists correction of COM alignments AND fearful/agitated when COM alignment is corrected

• sensation of falling when shifted toward correct vertical alignment

• may fix extremities and push away

• shift COM beyond limits of stability without weightbearing

• in medial/lateral form is associated with disregard, motor planning deficits

• may have disregard or neglect of involved extremity

what are the associated signs of postural vertical deficit?

• movement is variable

• may have motor planning difficulty

• light touch and JPS sensation may be lacking

• behavior may be impulsive or fear avoidant

• judgment may be poor or they demonstrate fear avoidance behavior

what is the outcome for postural vertical deficit?

dependent on the severity of cog/behavorial deficits and motor function

mild = good (restorative)

severe = bad (compensatory)