Adults Midterm: Spooky Edition

Visual system

Provides info (central + peripheral) about vertical orientation relative to the external environment & velocity of surrounding environment

Vestibular system

Provides info about the position and motion of the head

• Semicircular canals: sense angular acceleration

• Otolith organs (utricle + saccule): detect linear acceleration or translational movement of the head

Somatosensory system

Provides info about joint position [mechanoreceptors], muscle length + tension [muscle spindles, Golgi tendon organs], & body orientation relative to a support surface & position of body segments in relation to one another

CNS

Responsible for managing a constant stream of sensory info to make important motor decisions related to maintaining balance

Sensory re-weighting

Adjusting the relative importance of sensory info

• ex: increase reliance on one type of info & decrease reliance on another

• Depends on environmental constraints & changes to body functions after injury

Righting reflexes

Automatically maintaining an upright position of head & body when displaced

Vestibulo-ocular reflex (VOR)

Keeps eyes fixed on object while head and body are in motion

Vestibulospinal reflex

Maintains postural equilibrium during head movement

Types of postural strategies

1. Reactive strategies

2. Anticipatory strategies

Reactive strategies

1. Ankle strategy

2. Hip strategy

3. Stepping and reaching strategies

Ankle strategy

Small ankle movements (distal to proximal) used to control small, slow, swaying motions when standing on firm surfaces

• present during quiet standing

Hip strategy

Hip movements (proximal to distal) used when COM reaches outer limits of BOS

Stepping and reaching strategies

Changing base of support

• i.e. increase BOS to move COM over BOS

Anticipatory strategies

Prepositioning self relative to the direction of external force

• i.e. increasing BOS or lowering COM

“Ideal, Proper, Good” Posture

• Upright position against gravity that optimize the alignment of the spinal vertebrae & all adjacent structures

• Helps support joints & tissues and optimizes balance

• Helps optimize symmetrical loading of spine + spinal structures

• Promotes biomechanical effectiveness while moving

• Supports normal functions of internal organs

Tilt

• Deviation from vertical or horizontal alignment

• Results in one side being higher than the other

• Named for direction of the tilt:

  • anterior, posterior, left, right

Bend

• Occurs only in spine

• Series of tilts resulting in a curve

• Named for direction of the bend:

  • Backward, forward, left, right

  • flexion + extension

***Cannot have a bend without a tilt***

Rotation

• Occurs in vertical axis

• Named for direction of the rotation relative to something else:

  • Lateral, medial, left, right

  • internal + external rotation

Shift

• Translation of one body part’s COG relative to another

• Bends or tilts accompany shifts

• Named for direction of the shift:

  • Anterior, posterior, left, right

  • flexion + extension

You are evaluating a client who experienced a R CVA resulting in LUE motor impairments and generalized LE weakness/instability. They require SBA for ambulation using a hemi walker. One of their therapy goals is to feed their dog, which includes reaching for the dog bowl on the ground. You need to complete a balance assessment that aligns with this goal, and that looks at other aspects of static and dynamic balance. Which is the best assessment tool to choose and why?

1. Timed up and go

2. Functional reach

3. Berg balance scale

4. Tinetti

Berg balance scale

***tests for reaching items on the ground

A client who experienced a R CVA 2 weeks ago is participating in OT in an inpatient rehab setting. The client presents with L hemiparesis, impaired standing balance, and decreased awareness of the L side of the body. During a toilet transfer, the client attempts to stand before positioning the wheelchair and requires moderate assistance to maintain balance. Which intervention is MOST appropriate to improve the client’s safety during functional mobility?

1. Instruct the client to independently complete repeated sit-to-stand transfers to improve LE strength

2. Provide verbal cues to attend to the L side and establish a consistent transfer sequence before initiating movement

3. Place the wheelchair on the client’s L side to encourage increased use of affected extremities during transfer

4. Have the client practice transfers without verbal cues to promote independent problem-solving and motor learning

2. Provide verbal cues to attend to the L side and establish a consistent transfer sequence before initiating movement

An OTR is evaluating a client who has an ulnar nerve injury at the wrist level of the right dominant extremity. During which task would this injury be MOST evident?

1. Carrying a briefcase

2. Turning a key in the car ignition

3. Operating a desk calculator

4. Holding coins in the palm of the hand

2. Turning a key in the car ignition

***consider type of pinch being used (lateral (for key)) and activation of 1st dorsal interossei

Tendinopathy Progression of Therapeutic Interventions

1. Remove or modify aggravating factors: educate about positioning/body mechanics

2. Rest tissue

3. Recapture tissue extensibility: pain-free ROM and stretching

4. Strengthen: proximal to distal

***Throughout tx: provide education about preventing re-occurrence (positioning, body mechanics)

Lateral Epicondylitis (tennis elbow)

Interview / Special Testing - experiencing PAIN with the following:

• Resistive wrist/digital extension

• Gripping

• Wrist flexion while elbow is extended

• Lifting - esp when forearm is pronated

• Palpation to insertion of common forearm extensors

Lateral Epicondylitis - Treatment Protocol

1. Postural correction

2. Compensatory strategies

3. Wrist orthosis at night & during the day (activities, task, etc)

4. Counterforce brace/KT

5. Stretching

6. PAMs

7. Progress to strengthening

Medial Epicondylitis

Interview / Special Testing - experiencing PAIN with the following:

• Resisted wrist flexion

• Gripping

• Stretching wrist in extension while elbow is extended

• Palpation over insertion of common flexors of medial epicondyle

Medial Epicondylitis: Treatment Protocol

• Postural correction

• Night orthosis with wrist in neutral

• Stretching

• PAMs

• Soft-tissue mobilization/massage

• Compensatory strategies to maximize ADL performance

• Careful strengthening of involved muscle (once pain is minimal to resolved)

De Quervain’s Tensosynovitis

Entrapment or compression tendinitis of tendons contained within 1st dorsal compartment (abductor pollicis longus and extensor pollicis brevis)

• Pain with palpation over 1st dorsal compartment

• Pain with twisting wrist in radial deviation

• Pain with thumb extension

• Positive Finklestein’s maneuver

De Quervain’s Tensosynovitis: Common Interventions

1. Orthosis - restricting wrist and thumb motion

2. Avoid wrist deviations - esp with pinching

3. Gentle stretching

4. Careful progression of strength

5. PAMs (iontophoresis/phonophoresis most effective in early tx)

6. Soft-tissue mobilization/manual therapy

7. KT

Flexor Tenosynovitis (trigger finger)

• Stenosis of the A-1 pulley of finger flexor tendon

• As tendon glides proximally with finger flexion, the tendon is unable to pull thru the A-1 pulley due to increased bulk

• Results in a locking “triggering” of finger in flexion

Flexor Tenosynovitis (trigger finger): Common Interventions

Testing:

• Locking the finger in flexion

• Palpable nodule in the area of the A-1 pulley

• Pain in A-1 pulley

Treatment Protocol:

• Orthosis to block flexion of MCP joint and allow tissue to heal

• Build up handles

• Padded gloves

• Pacing of activities

Typical Peripheral Nerve Injuries

• Medial Nerve: carpal tunnel

• Ulnar Nerve: cubital tunnel, guyon’s tunnel

• Radial Nerve: PIN Syndrome, Supinator Syndrome, Radial Tunnel Syndrome, Palsy

Carpal Tunnel

Compression of the median nerve as it passes under the transverse carpal ligament

• Most common UE nerve entrapment

• Carpal bones form the “floor,” transverse carpal ligament forms the “roof”

• Contents of tunnel = 9 flexor tendons + median nerve

Carpal Tunnel: Interventions

1. Body mechanics: neutral wrist during rest, work, and sleep

2. Night orthosis/work orthosis to maintain neutral wrist position

3. Prevent repetitive movements of fingers

4. Prevent frequent, repetitive gripping

5. Differential tendon gliding, stretching, nerve gliding

6. Padded gloves

7. Built up handles

8. Anti-vibration gloves

Cubital Tunnel

• Second most common UE nerve entrapment

• Compression between medial epicondyle & olecranon

• Manifests as proximal & medial forearm pain (ache or sharp)

• Decreased sensation of dorsal & palmar SF & ulnar RF

• Weakness of interossei, adductor pollicis, FCU, and FDP of RF/SF

Cubital Tunnel: Common Interventions

Testing:

• Posture

• AROM

• Grip and pinch strength

• MMT

• Tinel’s over cubital tunnel

• Elbow flexion test

• Sensory testing

• Examine for signs of clawing or intrinsic muscle atrophy

Interventions:

• Avoid elbow flexion to relieve pressure

• Avoid weight-bearing on the elbow

• Avoid wrist flexion activities

• Night orthosis/sleeping posture

• Elbow pads

• Ulnar nerve gliding

• Proximal conditioning

• Ergonomic education

Radial Tunnel Syndrome

A compression neuropathy involving the posterior interosseous branch of the radial nerve

• Also called Posterior Interosseous Nerve (PIN) Syndrome

Radial Nerve Palsy

• Paralysis to all muscles innervated by the radial nerve

• Injury can occur proximally (“Saturday Night Palsy” or humeral fracture) or distally (crush, deep laceration)

• Unable to extend wrist or digits actively: “wrist drop”

***Treatment focuses on maintaining PROM, orthosis, prevent deformity, promote function

Common Ligament Injuries of the UE

• Elbow: ulnar and radial lateral collateral

  • Ulnar injury = “Tommy John’s”

• Thumb: skier’s vs. gamekeeper’s

• Digits: collateral ligament injuries to the MCP, PIP, or DIP (acute vs. chronic)

Ligament Injuries: Sprain Classifications

1. Grade I: ligament intact but diffuse individual fiber disruption

2. Grade II: partial tearing of ligament

3. Grade III: complete rupture of ligament(s) from bony surface

Skier’s vs. Gamekeeper’s Thumb

Both involve ulnar collateral ligament (UCL) of the thumb

• Skier’s Thumb: traumatic, acute injury

• Gamekeeper’s Thumb: chronic onset

***May require immobilization or surgery

Testing: varus/valgus motion

• compare both thumbs for hypermobility

Dupuytren’s Disease

• Genetic component (“Viking” disease)

• Abnormal thickening of the fascia in the palm

• Firm cords and lumps develop in the palm

• Progression causes tendons to flex in the palm

• Usually not painful

• Requires surgery (open) or Xiaflex injection

• Orthotic protocol 3-6 months

Ischemic Stroke

• Occurs when there is decreased blood flow to the brain

• Accounts for about 87% of all strokes

• Classifications:

  • Thrombotic

  • Embolic

  • Lacunar

Modifiable Stroke Risk Factors

1. Metabolic risk factors: hypertension, diabetes, disorders of heart rhythm (e.g. atrial fibrillation), & hypercholesterolemia

2. Behavioral risk factors: smoking/tobacco use, excessive alcohol use, physical inactivity/sedentary behavior, low cardiorespiratory fitness, poor diet & nutritional intake, & sleep habits

3. Psychosocial risk factors: depression, social isolation, & loneliness

Spasticity

An increased response to stretch

• Reflex hyperactivity characterized by:

  • (1) velocity dependent stretch reflexes

  • (2) increased resistance to movement

  • (3) stereotypic posturing

  • (4) excessive co-contraction

  • (5) stereotypical movement synergies

• GH IRs, elbow & wrist flexors are commonly affected by spasticity

• Loss of ER

Hypotonicity

Characterized by low muscle tone or flaccidity

Hypertonicity

1. Intermittent: fluctuations in tone that are dependent upon activity, body posture, and balance demands

2. During Voluntary Movement: difficulty initiating and sequencing muscle activation (stereotypical patterning)

3. Positional: results from alterations in joint alignment and subsequent changes in muscle length-tension relationships

Scapulothoracic Position

The position of the scapula on the ribcage (i.e. biomechanical alignment) is essential for creating a stable base for effective reaching patterns.

Under normal conditions, the scapular position at rest =

• Superior border is slightly tipped anteriorly

• Medial border lies in a superomedial-inferolateral position

• Glenoid fossa rotated in upward direction

After a stroke, the resting position of the scapula can change and be oriented in a downwardly rotated, depressed, and retracted position. This can be due to trunk control problems and/or imbalance in scaapulothoracic musculature.

Abnormal Scapulohumeral Rhythm

During active humeral elevation, changes in motor control can alter normal scapulohumeral rhythm, including:

• Delayed onset of lower trapezius activation

• Early and longer activation of infraspinatus in individuals without shoulder pain (important for achieving humeral rotation to reduce subacromial impingement)

• Delayed and early inactivity of serratus anterior in individuals with shoulder pain

Pain Following a Stroke

UE pain is common after experiencing a stroke (not common during acute phases; accounts for 10%-45% of stroke patients)

Types of Pain:

1. Joint pain (nociceptive) occurs during alterations in biomechanical joint motion, passive and/or active (impingement); can occur in presence of subluxation

2. Muscle pain (nociceptive) occurs when tight/hypertonic/spastic tissue is moved too quickly, with too much force, or with poor alignment

3. Central post-stroke pain (neuropathic) occurs when sense perception is altered (e.g. hyperalgesia & allodynia) and can be induced OR independent of stimulation

4. Complex regional pain syndrome is characterized by increased sensitivity to tactile stimulation, vasomotor changes (i.e. edema & changes in skin temperature/color), limited ROM, and osteopenia

Mental Health and Behavior Following Strokes

Mental health problems are commonly experienced after a stroke. About 1/3 of stroke survivors experience depression, and about 1/4 experience anxiety.

• Increase the risk for another stroke, disability, and mortality; decreased participation, and poorer quality of life

• Many people do not receive intervention for mental health problems post stroke

Other mental health and behavioral changes can include:

• Impulsivity

• Apathy

• Pseudobulbar affect (emotional lability - involuntary bouts of crying, laughter, or anger)

• Decreased self-esteem

Secondary Complications from Strokes: Subluxation

Characterized by partial separation of the humeral head and glenoid fossa

• Can occur in different directions (most commonly anterior & inferior)

• Does not always cause a problem, but shows that soft tissues are stretched / relaxed

Reasons for Subluxation Include:

• Flaccidity of scapular stabilizers/approximators (e.g. supraspinatus, upper traps, deltoids, serratus anterior) and hypertonicity of downward and internal rotators (e.g. pec minor, subscapularis, lat dorsi)

• Postural malalignment (e.g. bending/laterally flexing towards affected side)

• Mishandling (e.g. pulling on paretic limb) and poor positioning (e.g. in bed or wheelchair)

• Gravity

Standardized Motor Control Tests

• Fugl-Meyer

• CAHAI

• ARAT

• ABILHAND

• FUEL

Stroke Rehab

A combination of approaches to interventions must be considered. These approaches are informed by practice setting, stage of recovery (i.e. time after stroke), and client/practitioner preferences

Stroke Rehab: Modify Approach

Initially, a modify approach may be used to promote/facilitate early engagement in ADLs while protecting the affected extremity; this can also target changes to the home environment

• Involves changing how tasks are performed, the environment in which they are performed, and/or objects and their properties

  • Education & training (e.g. assistive devices, hemi-dressing techniques, home modifications)

• Caution: over-reliance on modify approaches early on in the recovery process may promote/reinforce learned non-use

PNF

Techniques that use awareness of body position and movement - through specific commands and cues directed at muscles & nerves - to help a client achieve new movement patterns

• Emphasis placed on tri-planar movements (i.e. diagonal patterns) including head & neck

• Practitioners using PNF employ a multisensory approach:

  • Vision (incorporate eye movement)

  • Audition (tone of voice, type of commands used)

  • Tactile sensation (touch used to facilitate movement patterns)

PNF Core Concepts

1. Resistance: used to facilitate, reinforce, or strengthen specific movements

2. Stretch: quick stretch to tap into reflex

3. Traction: elongate or lengthen

4. Approximation: compression

5. Body mechanics/position: most stable to least; consider clinician’s mechanics as well

Task-Oriented Approach

“Normal” movement emerges from the dynamic interaction of body systems (motor/action, sensory/perceptual, cognitive) as influenced by task objectives & environmental constraints

• Intervention can target any or all factors (person, activity, environment); can be remedial (restore or improve performance) or adaptive (change conditions or ways of doing), or both

• Addresses movement in context (during performance of an activity) versus movement alone

  • Learn by doing - which aligns with how movement naturally emerges

  • Emphasis placed on analyzing own movement & solving problems

Slings

Pros:

• May protect from injury during transfer

• Enables therapists to control other areas of the body (trunk) during function training

• May prevent prolonged dangling of UE; relieves pressure on brachial plexus

• Supports weight of the hypotonic UE

Cons:

• May contribute to learned nonuse & soft tissue tightness/loss of tissue extensibility due to prolonged immobilization

• May create dependence on passive positioning devices

• May predispose to shoulder pain from shortened internal rotators

• May initiate SHS development (immobility leading to swelling, shortening, & pain)

• Blocks sensory input

Arm Supports

Lap Tray Pros:

• Shoulder can be positioned in neutral rotation vs. internal rotation

• Arm is free to move, can be seen & used for functions

• Useful for individuals who use a wheelchair as a primary mobility aid

Lap Tray Cons:

• Can be limiting to people who can transfer or use urinal independently

• Shifts in body position changes shoulder alignment

• Depending on positioning, patient may be at risk for overcorrecting an inferior subluxation

• Can be considered a restraint if the client is unable to independently manage

Arm Rest Pros:

• Positions shoulder in neutral rotation

• Supports weight of UE while client is seated

• Person can access & move in/out of wheelchair

Arm Rest Cons:

• May cause a shift in shoulder alignment during weight changes, esp. if strapped in

• Risk of hemi-inattention while strapped in

Preparing the Shoulder for Movement

Before starting movement interventions for a hemiparetic shoulder, assess posture & AROM. If AROM is limited, address the underlying cause(s), potentially including passive ranging.

To prevent shoulder pain during passive overhead movements, first assess scapular mobility/glide in all directions & external rotation of GHJ

• Avoid elevating humerus above 90 degrees without scapular upward rotation & GH external rotation

• Avoid the use of overhead pulleys or self-ranging

• Approximate the GHJ if subluxation is present, & do not pull on the limb

• Range to the point of light resistance

Mirror Therapy

Type of rehabilitative approach where the reflection (visual input) of a moving non-affected limb gives the illusion of movement in the affected limb

• can be used at any stage of recovery, regardless of limb function

Mental Practice / Motor Imagery

• Involves visualizing & rehearsing movement

• 2 forms:

  • External/Visual: individual imagines themself moving

  • Internal/Kinesthetic: individual is taught to imagine the sensation of movement

• Activates areas of the brain responsible for imagined movement (like mirror therapy)

Stages of Pressure Sores

1. Non-blanchable erythema of intact skin

2. Partial-thickness skin loss with exposed dermis

3. Full-thickness skin loss

4. Full-thickness loss of skin & tissue

Stages of Wound Healing

1. Hemostasis (immediately): cessation of bleeding via vasoconstriction & clotting; scab is formed; exudate present & can cause pain & swelling

2. Inflammatory (several days): phagocytosis occurs (cleaning process); pain, redness, swelling, & heat present at site of injury

3. Proliferation (several weeks): fibroblasts migrate to wound site; collagen synthesis; blood supply increases; scar tissue forms; painful symptoms generally start to fade

4. Maturation/Remodeling (several months - years): fibroblastic activity continues; scar becomes stronger, but not as strong as normal tissue

Stages of Fracture Healing

1. Hematoma (days 1-5): blood vessels rupture & begin clotting

2. Fibrocartilaginous (days 5-11): formation of new capillaries; cartilage tissue forms

3. Bony Callus (days 11-28): cartilaginous callous begin to calcify; blood vessels continue to proliferate; bony callus forms

4. Bone Remodeling (days 18+ (months - years)): hard callus undergoes continuous remodeling

FUEL (Functional Upper Extremity Levels)

1. Nonfunctional: involved UE not incorporated into daily activities; decreased awareness of involved UE; no AROM present

2. Dependent Stabilizer: involved UE incorporated into activities as stabilizer, but is placed by less-involved UE or by caregiver; increasing awareness of involved UE; some AROM may be present (scapular, gravity eliminated), but patient is unable to initiate placement

3. Independent Stabilizer: some AROM in involved UE & able to independently position during activities (w/o use of other UE); used primarily as weight to stabilize; no active hand use

4. Gross Assist: involved arm/hand used actively to assist in accomplishing simple functional activities; involved UE may be influenced by synergistic movements or have extreme weakness; gross grasp may have developed, but no functional release; fine motor coordination not functional

5. Semifunctional Assist: involved arm/hand used in activities requiring active motor control for pushing, pulling, & stabilizing; gross grasp & release have developed, & some individual finger movements may be developing (though measurements for grasp, pinch, & coordination are below norms); hand is able to assist with fastenings

6. Functional Assist: involved arm/hand have full AROM; able to use involved UE for all activities & fine motor tasks, but remains an assistive UE with mild awkwardness & weakness

7. Fully Functional: involved UE restored with complete function; able to use dominant UE (if premorbidly dominant); strength, grasp, pinch, & coordination measures are all WNL

Spotting a Stroke (Be Fast)

B - balance: loss of balance, headache, dizziness

E - eyes: blurred vision

F - face: one side of face is dropping

A - arms: arm and/or leg weakness

S - speech: difficulty with speaking

T - time: call for ambulance immediately

CVA Effects on Different Brain Areas

1. Frontal: movement, emotions, memory, language, social, sexual behavior, & personality

2. Temporal: hearing, speech, memory, & emotions

3. Parietal: bodily sensations

4. Occipital: processing vision

5. Cerebellum: balance & coordination

6. Brainstem: breathing, heart rate, & temperature