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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