Week 5 combined

Levels of consciousness

Levels of consciousness

Alert

Lethargic

Obtunded

Stupor

Coma

Alert

Patient is awake and attentive to normal stimuli

Able to interact with people

Lethargic (somnolent)

Patient arouses with stimuli (tapping, shaking)

Able to stay awake for a time but falls asleep when not stimulated enough

Decreased awareness

Patient may have difficulty focusing on task or losses train of thought

Oriented and not confused

Obtunded

Patient is difficult to arouse

Confused when awake

Needs constant stimulation to keep awake

Stupor (semi-comatous)

Patient responds only to strong, noxious stimuli then immediately returns to unconscious state if stimulus stops

Patient is unable to interact with clinician

Coma

Patient cannot be aroused by any type of stimulus

May or may not have reflexes

Cognitive testing

Assessment of attention

Orientation

Memory

Abstract thought

Ability to perform calculations or construct figures

Judgement

Delirium

Severe confusion that can develop in a few hours or days

Caused by metabolic imbalance (low Na), medication, infection, alcohol or drug intoxication/withdrawal, severe illness

Pt demonstrates offensive, loud, and talkative behaviors

State of disorientation characterized by:

• Irritability

• Agitation

• Paranoia

• Hallucinations

Left and Right Hemispere Facts

Work together and communicate - corpus collosum

Some parts of the brain have more functions than others

Individuals have preferences of what interests them and then develops that skill more

Normal Left Hemisphere Functions

Analytic thought- Problem solving

Reasoning- Deductive and inductive

Logic- Facts, Details, Based on validity

Number skills- Calculations

Science skills

Curiosity

Impulsiveness

Verbal communication

Language- Comprehension, expression, reading, writing

Right sided visual field- Controls the right side vision of each eye

Right sided motor control- Controls the right side of the body

Left Hemisphere Injury

Impaired analytical thought, reasoning, logic, mathematical skills

Visual problems (field cuts to the right, tunnel vision or blurred)

Easily frustrated because they are misunderstood

Inappropriate use of yes/no

Perseveration/echolalia

Inability to name objects but knows what to do with them

Inappropriate laughing/crying

Language- Broca’s aphasia, Wernicke’s aphasia, Global aphasia

Broca’s aphasia

Aka Expressive aphasia

Brodmann’s areas 44, 45

Usually good comprehension with poor verbalization

Intelligence intact

May use 1-2 words

Switch letters in words like sloon for spoon

May use main words and leave out conjunctions like but, and, or

Apraxic speech – messages from the brain aren’t getting to the tongue and other facial muscles to help form words

Patients with expressive aphasia are aware of their deficits

Strategies to use for patients with Broca’s aphasia

Eliminate distractions in the room

Give the patient multiple choice options

Ask yes/no questions

Encourage the patient to use gestures and communication devices

Give the patient time to answer (try not to finish his sentence)

Wernicke’s aphasia

Aka receptive aphasia

Brodmann’s area 22, 39, 40

Poor auditory comprehension

Verbalization is fluent and grammatically correct; however, the content is unintelligible

Perseverates

Patients are unaware that they have a deficit

Strategies to use for patients with Wernicke’s aphasia

Eliminate distractions in the room

Get the patient’s attention

Simplify your commands

Give one step commands at a time

Allow the patient time to process the info and respond

Use gestures and emphasize key words

Demonstrate the task you want the patient to do

Global aphasia

Injury to the areas of the brain that result in both expressive and receptive aphasia

May say the same words or phrases over and over like "I know" and “ok"

May use varying intonation to have different emphasis and tone based on the situation

Strategies to use for patients with Global aphasia

Eliminate distractions

Get the patient’s attention

Allow the patient time to process the info

Don’t speak for the patient

Strategies to use for patients with Left Hemisphere Injury

Use adult language, normal tone and volume of voice

May have the patient write to assist in communication

Give immediate feedback

Simplify commands

Use gestures or picture boards

Yes/no questions

Check for patient comprehension by: repeating back what you think the pt is saying, asking him to repeat or showing you the steps

Normal Right Hemisphere Functions

Attention- Sustained, Divided, Alternating, Visual and auditory

Reasoning- Deductive and inductive

Memory- immediate, Short term, Long term, Working

Problem solving- Daily living problems

Creativity- Imagination, Visualization, Daydreaming

Music

Abstract concepts

Spatial awareness

Inhibition- Deciding what is appropriate or safe behavior

Initiation- Beginning a task, Asking for help, Starting a conversation

Orientation- Name, date, time, place, situation

Organization- Thoughts, Information

Emotions

Holistic approach

Non-verbal communication

Left sided vision field

Left sided motor control

Right Hemisphere Injury

Impaired attention

Hemi-anopsia

Difficulty recalling info from memory

Difficulty with solving problems of everyday life

Impaired inhibition

Decreased initiation-

Impaired orientation

Difficulty with organization

Strategies to use for patients with Right Hemisphere Injury

Eliminate distractions and get the patient’s attention

Set up a routine

Simplify directions

Ask patients to repeat instructions

Slow pt down if impulsive or moving too fast

Redirect the patient back to the task at hand

Have patient return gaze to a point on the left side of his visual field to establish a point of reference and get him to attend to that side

Work on initiation by sabotaging a task and see how patient responds

Practice, practice, practice

Indications for PNF

Increase strength, flexibility, ROM, endurance, stability, mobility, coordination of movement

Facilitate neuromuscular control

trunk patterns

D2 UE flexion = lifting pattern (D2 UE extension = reverse lift)

• At end range, there’s facilitation of trunk extension, elongation of the opposite side of trunk, and weight shifting to the side the arm is lifted.

D1 UE extension = chopping pattern (D1 UE flexion = reverse chop)

• At end range, there’s facilitation of trunk flexion, shortening of the trunk on the side of the arm is lowered, and weight shifting to the side the arm is lowered.

Contraindications for PNF

Early stages of soft tissue healing after injury or surgery

Acute or active arthritic conditions

Any movement that the doctor has deemed contraindicated or unsafe

Goals for PNF

Promote functional movement by facilitation, inhibition, strengthening, or relaxation of muscle groups

Outcomes of PNF

Establish head and trunk control

Initiate and sustain movement

Control shifts in center of gravity

Control the pelvis and truck in midline while the extremities move

Basic principles of PNF-refresher (10 essential components)

Manual contacts

Body position and body mechanics

Stretch

Manual resistance

Irradiation (overflow)

Joint facilitation

Timing of movement

Patterns of movement

Visual cues

Verbal input

UE Patterns of PNF-refresher

UE D1 flexion (feeding pattern)- Shoulder flexion/adduction/external rotation

UE D1 extension- Shoulder extension/abduction/internal rotation

UE D2 flexion (cheerleader hooray pattern)- Shoulder flexion/abduction/external rotation

UE D2 extension- Shoulder extension/adduction/internal rotation

LE patterns of PNF-refresher

D1 flexion (putting on a shoe)- Hip flexion/adduction/external rotation

D1 extension- Hip extension/abduction/internal rotation

D2 flexion (fire hydrant)- Hip flexion/abduction/internal rotation

D2 extension- Hip extension/adduction/external rotation

Challenging positions while doing extremity patterns

Quadruped position

Sitting

Standing

Scapular and Pelvic patterns

Done best in the side-lying position

These patterns assist with functional movements like rolling, reciprocal movements of UE/LE, scooting, and gait

Scapular patterns help with UE function, cervical and thoracic spine alignment

Pelvic patterns help with LE function and lumbar spine alignment

Scapular patterns

D1 flexion/extension: anterior elevation and protracted (shoulder shrug) - start at the 1:00 position move into the 7:00 position of posterior depression and retracted (hey, big boy)

D2 flexion/extension: posterior elevation-scapula is elevated and retracted (look at my pects) – start at the 11:00 position and move into the 5:00 position of scapula is anterior depression and protracted (putting something in your front pocket)

Pelvic pattern

D1 flexion/extension: start at the 1:00 position move into the 7:00 position of posterior depression (“sit back into my hands”)

D2 flexion/extension: really isn’t done but would be 11:00 to 5:00 movement

Trunk pattern is the

Foundation of controlled movement

Upper trunk patterns-consists of synchronous UE PNF patterns using both UEs

Promotes trunk musculature activation especially rotators and increases the overflow response in the trunk

Lead arm determines the specific name of the trunk pattern and is the hand that is free to move (the arm that is not holding the other arm)

PNF techniques

Multiple techniques to use depending on what the goal is

• Example: isometrics to increase stability, isotonic movements to increase ROM and function

Techniques can be divided into the primary focus that technique has on motor control stages (mobility, stability, controlled mobility, and skill)

Rhythmic initiation ( improves mobility)

Sequential application of first passive, then active assisted, then active or slightly resisted motion

Good to use as a teaching tool

Rhythmic rotation ( improves mobility)

To promote tone reduction and relaxation

Application of slow rotary movements about a longitudinal axis

Hold relax ( improves mobility)

Purpose is to increase passive joint mobility and decrease movement-related pain

The limb is moved into the limit of the pain-free range

Isometric resistance is applied to the antagonist muscle or the agonist

The body segment is moved to the new range of motion

Hold relax active movement ( improves mobility)

Only one direction

Isometric resistance is applied to facilitate the agonist muscle in the shortened range

Then the limb is passively moved into a point in the lengthened position

Patient actively or with resistance pulls up into the beginning position

Repeat until there is no more gain in ROM

Contract relax (inc mob)

Effective when addressing decreased length in two-joint muscles and when pain is not a significant factor

Used to increase passive range and soft tissue length

Patient or therapist moves body part to the end of the available range then says “turn and push”. Therapist resists an isotonic concentric contraction to the rotational component while doing isometric contraction of the other shortened mm followed by relaxation then active movement into the new range

Alternating isometrics ( improves stability)

Isometric contractions of both agonist and antagonist muscle groups are facilitated in an alternating manner

Smooth transitions

Rhythmic stabilization ( improves stability)

Co-contraction of muscles surrounding the target joint using a rotatory force

Promotes stability and balance, decreases pain upon movement, and increases range of motion (ROM) and strength

Slow reversal (controlled mobility, and skill)

Concentric contraction of muscles in an agonist pattern is facilitated through manual contacts and verbal cues

Fatigue is minimized by rhythmically alternating between agonist and antagonist muscle groups

Slow reversal hold ( improves controlled mobility, skill, and stability)

Concentric contraction of muscles in an agonist pattern is facilitated through manual contacts and verbal cues

A resisted isometric contraction is held at the completion of range in each direction of the chosen pattern

Appropriate for use with single extremity or trunk patterns as well as functional movements

Agonistic reversals ( improves controlled mobility and skill)

To facilitate functional movement throughout a pattern or task

The agonist muscle groups are targeted both concentrically and eccentrically

Resisted progression (inc skill)

Focuses on the task of locomotion

Resistance is applied during functional activities

This technique may be applied during crawling, creeping, or walking

PNF technique for pain

Alternating isometric

hold relax

rhythmic stabilization

PNF technique for dec strength

agonsitic reversal

rhythmic stabilization

slow reversal

PNF technique for dec ROM

alternating iso

contract relax

hold relax

hold relax active

rhythmic initiation

PNF technique for dec coordination

alternating iso

agonistic reversal

rhythmic initiation

slow reversal

PNF technique for dec stability

alternating iso

agonistic reversal

rhythmic stabilization

PNF technique for movement inititation

rhythmic initiation

hold relax active

PNF technique for muscle stiffness/hypertonic

rhythmic initiation

rhythmic rotation

hold relax

PNF technique for dec endurance

alternating iso

rhythmic stabilization

slow reversal