week 4-8 combined

Sensory system

Vision

Vestibular

Somatosensory

Components of the postural control system

Limits of stability

Sensory organization

Eye head stabilization

Musculoskeletal system

Motor coordination

Predictive central set

Environmental adaptation

Sequence of development of postural control

Righting reactions

Protective reactions

Equilibrium reactions

Nashner’s model of postural control in standing

Postural control involves what three strategies

Ankle strategy

Hip strategy

Stepping strategy

Age-related changes in coordinated movement

Decreased strength

Slowed reaction time

Decreased ROM

Postural changes

Impaired balance

Age-related changes in postural and motor control

Balance strategies in sitting

• Trunk muscle activation

• Anticipatory control of posture occurs before voluntary movement by 9mo old

• Anticipatory control of posture increases as children get older

Balance strategies in standing

• Older adults have more spontaneous sway than younger people

• Possibly due to effects of gravity or to get more sensory info for postural control

• If eyes closed, older adults stand more asymmetrical

Postural sway

Normal sway- 10th of inch

Parkinson sway- rigid- not a lot of sway

Ataxia sway- increased

UE D1 Flexion

Shoulder flexion, adduction, external rotation; elbow flexion or extension, supination; wrist flexion and radial deviation; finger flexion

Hand to mouth feeding motion or throwing a scarf over the opposite shoulder

UE D1 Extension

Shoulder extension, abduction, internal rotation; elbow flexion or extension, pronation; wrist extension and ulnar deviation; finger extension

Throw trash away motion

UE D2 flexion

Shoulder flexion/abduction/external rotation; elbow flexion or extension, supination; wrist extension and radial deviation; finger extension

Cheerleader hooray or throwing a wedding bouquet over the same shoulder motion

UE D2 extension

Shoulder extension/adduction/internal rotation; elbow flexion or extension, pronation; wrist flexion and ulnar deviation; finger flexion

Placing a sword in its sheath motion

LE D1 flexion

Hip flexion/adduction/external rotation; knee flexion or extension; ankle dorsiflexion and inversion; toe extension

Bring the foot to the opposite knee to put on a shoe motion

LE D1 extension

Hip extension/abduction/internal rotation; knee flexion or extension; ankle plantarflexion and eversion; toe flexion

Putting on pants one leg at a time motion

LE D2 Flexion

Hip flexion, abduction, internal rotation; knee flexion or extension; ankle dorsiflexion and eversion; toe extension

Dog using a fire hydrant motion

LE D2 Extension

Hip extension, adduction, external rotation; knee flexion or extension; ankle plantarflexion and inversion; toe flexion

Kicking a soccer ball motion

2 main PNF Stretching Techniques

Hold-relax

Hold-relax active

Hold-relax

Lengthen the tight muscle (agonist) to the point of resistance

Have the patient do an isometric contraction (5-20 seconds) of the tight muscle (agonist) then relax

OR

do an isometric contraction of the opposite muscle (antagonist) then relax (in Ther ex, this was called Agonist contraction)

The limb is then passively moved to the new position and repeated

Example: if there is a bicep contracture, lengthen the bicep (agonist) as much as you can then the patient does an isometric contraction for 10 seconds of the bicep followed by relaxation of the muscle. Passively lengthen the bicep again in the new range and repeat

Hold-relax Active

Move the limb to the point of tissue resistance in the tight muscle (agonist)

The patient performs resisted isometric contraction of the tight muscle for 10 sec followed by relaxation of the muscle, the therapist passively moves the muscle into the new lengthened range and the pt actively does a concentric contraction back to the starting position

Example: 45 degree flexion contracture of the bicep – patient would do a resisted bicep isometric contraction for 10 seconds then relaxes and the therapist moves the limb into new extended range followed by active bicep contraction; repeat

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

• Circle and square test

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

Right sided motor control

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

Problem solving

Creativity- Imagination, Visualization, Daydreaming

Music

Abstract concepts

Spatial awareness

Inhibition- Deciding what is appropriate or safe behavior

Initiation

Orientation

Organization

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

• Inability to recall time, place, situation, and other personal info

• Impaired left/right discrimination

• Left side neglect or inattention

• Unable to navigate in unfamiliar areas

Difficulty with organization

• Impaired ability to stay on topic in a conversation

• Difficulty getting thoughts verbalized into an intelligent speech

• Difficulty understanding and relating to incoming info

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 of PNF

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

Outcomes for 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

Leading cause of stroke

Obesity

Diabetes

Smoking

Atrial fibrillation

High Blood Pressure

High Cholesterol

Stroke prevention

Healthy diet

Healthy weight

Physical activity

No smoking

Limit alcohol

Etiology of CVAs

Ischemic cerebrovascular accidents (CVAs)

• ~87% of all CVAs are caused by ischemia1

Hemorrhagic CVAs

• 40% of hemorrhagic CVAs will die

Transient ischemic attacks (TIAs)

Ischemic

Thrombotic

• Atherosclerosis

Embolic

• A-fib

• MI

• Valvular disease

Hemorrhagic causes

Intracerbral hemorrhage

Subarachnoid hemorrhage

Arteriovenous malformation

Intracerebral hemorrhage

Vessel malformation

Changes in the integrity of the vessels due to HTN and aging

Subarachnoid hemorrhage

Aneurysms

Vascular malformations

Arteriovenous malformation

Congenital

No capillary bed (arteries and veins are connected directly)

Transient Ischemic Attack (TIA)

Temporary loss of blood supply

Same symptoms as CVA but usually resolves in 24 hrs

1/3 of people with a TIA will have a CVA in 1 year

Symptoms of stroke

Sudden numbness or weakness in the face, arm, or leg, especially on one side of the body

Sudden trouble speaking, or difficulty understanding speech

Sudden trouble swallowing

Muscle stiffness

Sudden trouble seeing in one or both eyes

Sudden trouble walking, dizziness, loss of balance, or lack of coordination

Sudden severe headache with no known cause

Behavioral changes, confusion, memory loss

Recovery

Unique

Most significant recovery within the first 3-6 months but can continue to improve for years to come

10% recover almost completely

25% mild impairments

40% moderate to severe impairments needing special care

10% need placement in a long term facility

15% die after event

What to do if change is noted

Try to find out exactly what has changed

• Arousal level

• Orientation

• New weakness

• Worsening of previous condition

Act F.A.S.T.

Notify patient’s nurse

Notify supervising PT

FAST

Facial droop

Arm strength

Speech impairment

Time to call 9-1-1

Diagnostic testing for CVA

CT scan

• May not detect embolic if it is small

MRI

Carotid ultrasound

Cerebral angiogram

Echocardiogram

Acute medical management

Monitor vitals

Pharmacologic – blood thinners to improve flow and dec tissue damage if not a hemorrhagic stroke

Thrombolytic medications for ischemic strokes

• Tissue plasminogen activator (tPA) has to be given by IV within 3-4.5 hours of event to dec the neuro damage, dec blood clots, and inc blood flow;

• Tenecteplase (TNK) is a single bolus dose used for MI within 30 minutes of onset; being used for CVA but not FDA approved for CVA; maybe safer and more effective; breaks up clots already present but doesn’t prevent them

Surgical – clipping aneurysm, excision of an abnormal vessel, or evacuation of a hematoma

Modified Rankin Scale

It is a functional outcome measure of stroke that reflects the overall level of disability.

Score= 0-6

Fugl-Meyer Assessment (FMA)

Stroke specific performance-based impairment index

Designed to assess the severity, describes the motor recovery, helps plan and assess treatment for a patient post stroke hemiplegia

5 Domains:

• Motor func (UE,LE)

• Sensory func (lt touch on 2 surfaces of the arm and leg, and position sense for 8 jts)

• Balance (7 tests: 3 seated and 4 standing)

• Jt ROM (8 jts)

• Jt pain

Materials needed: mat or bed, ball, cotton ball, pencil, reflex hammer, small can or jar, goniometer, stopwatch, blindfold, chair, bedside table

Scoring is based on direct observation of performance and scored on the basis of ability to complete the item using a 3-point ordinal scale where 0=cannot perform, 1=performs partially and 2=performs fully. The total possible scale score is 226.

Arterial occlusions

Anterior cerebral artery occlusion - rare

Middle cerebral artery occlusion – most common

Vertebrobasilar artery occlusion

Posterior artery occlusion

Changes in mentation and cognition

Arousal

Orientation

• SLUMS

• Mini Mental

Attention

Mentation

Cognition

Memory

Memory is tested by

Immediate recall

Ability to recall words after a few seconds

short term memory

Ability to recall 3 words after 5 minutes and at least 2 words in 30 minutes

Anterograde amnesia (antero=forward) - loss of the ability to create new memories after the injury; never gets better

long term memory

Ability to recall past events

High school, wedding day, graduation for PTA school

Retrograde amnesia (retro=backward) - loss of pre-existing memories before the injury; often returns

Homonymous hemianopsia-

Left hemiparesis then loss of left half of the visual field of each eye

Sensory impairments comes from the

Parietal lobe – proprioception

Motor and Tone

Initial flaccidity then spasticity

Spasticity in proximal muscle groups

Motor planning deficits

Abnormal posturing and positioning

Fall risk

Inc risk of thrombophlebitis due to dec calf pump

Pain in muscles and joints

Communication problems

Frontal and temporal lobes – Broca’s, Wernicke’s, or global aphasia

Dysarthria

Emotional lability-R hemi

Depression

Orofacial deficits

Cranial nerve involvement if stroke is in brain stem or midbrain

Dysphagia

Dec coordination between eating and breathing

Respiratory

Dec lung expansion due to weak diaphragm and external intercostals

Pneumonia, atelectasis, weak cough

Inc RR due to compensation of dec lung expansion

Dec exercise endurance

Inc O2 consumption leads to fatigue