PHTY3070: Oral Defence Revision

Gait

Postural control

Coordination

Three main deficits of Friederich's Ataxia (FA)

Assess falls potential for elderly

Can also be useful for ataxias

Quick and easy Ax

Dynamic gait index (DGI)

Gait, function, ADLs and neurological

Long to perform, sometimes not practical

0 = normal 159= disability

Friedereich's ataxia rating (FARS)

Rating of ataxia

Quick 30s tests - coordination Ax

0 = normal 40 = disability

Scale assessment and rating of ataxia (SARA)

4 subscales - posture, kinetics, speech disturbance and oculomotor

Allows to determine where main deficits are

0 = normal 100= disability

International cooperative ataxia rating scale (ICARS)

Hypotonia

Ataxia

Dysarthria

Tremor

Ocular motor dysfunction

S &S of cerebellum dysfunction

Controls onset, level and force production by mm for mvt and postural equilibrium

Predictive compensatory modification of reflexes for preparation of mvt

Comparator between sensory and motor

Cerebellum functions

Balancing and coordinating eye and head movements

Vestibulocerebullum

Postural instability in stance and gait

Decrease postural reflexes

Nausea

Vestibulo-ocular reflex

Cerebellar nystagmus

Vestibulocerebellum dysfunction

Postural tone and motor execution

Spinocerebellum

Hypotonia

Loss of programmed deceleration

-hypermetria, rebound, lack of motor plasticity, gait ataxia, intention tremor

Movements are random

Spinocerebellum dysfunction

Overshooting intended position

Hypermetria

Reflex that occurs when limb attempts to move against resistance and is suddenly removed

Rebound phenomenon

Planning, initiation and visual guidance of movement

Neocerebellum dysfunction

Difficulty performing movement in smooth motion, performed in steps

Movement decomposition

abnormal weakness or lack or energy

Athenia

Improper measurement of distance in muscle movements

Dysmetria

Rapid and alternating movements

Dydiadochokinesia

Slurred speech, voice changes, change of speech rate

Dysarthria

Defective timing of sequential contraction of agonist/antagonist mms

Dysynergy

Response to perturbations

Loss of anticipatory movement

1. Appear in trunk, extremities, head, mouth and tongue (speech)

2. Incorrect programming - rate, range, duration and force of mm contractions

3. Inability to regulate posture - decrease efficiency and smoothness of gait

4. Disruption in rhythm during swing and stance phase - irregular duration

Ataxia S&S

Hereditory ataxia, most common

Degenerative

Fredereich's Ataxia

DNA testing, EMG, CSF, MRI and nerve conduction velocity

Usually less than 25 yrs old = severe

30-40 yrs life expectancy

FA diagnosis & prognosis

Mutation of frataxin gene --> Oxidative stress --> mitochondria damage

FA pathophysiology

Diabetes mellitus

Hypertrophic cardiomyopathy

Pes cavus

Spinal scoliosis

Common comorbities of FA

Decreased sensation

Ataxia

Weakness and fatigue

Dysarthria and dysphagia

UL weakness

Hyporeflexia

Postive babinski

Spasticity

FA S&S

Proprioception in joints and muscles

Spinocerebellar tract

Varied group of disorders - 30

Inherited autosomal dominant

Age > 18 yrs

Spinocerebellar ataxia

Degeneration of cerebellum and SC

Progressive atrophy and spasticity

Spinocerebellar pathophysiology

Generally fatal 10-20yrs of first symptoms

MRI = atrophy of cerebellum

Genetic testing definitive for 50% of cases

Diagnosis and prognosis of spinocerebellar ataxia

Ataxia

Slow eye movement

Visual loss

Anticipation

S&S of spinocerebellar ataxia

Genetic disorder is passed onto next generation

Anticipation

Hand and foot tapping

Finger to nose

Pronation/ supination

Finger strumming

Open and close fist

Heel to shin

Legs cycling

Alternating hip/knee flexion

Reciprocal mvts of all joints

Low level coordination testing

Heel to toe walking

Braiding

Running/ skipping

Star jumps

Cross over jumps

Skipping with rope

Copying sequences of 4 limb patterns

Ball skills (one hand bouncing etc)

High level coordination testing

1. Postural tone

2. Coordination of movement

3. Position of feet

4. Affect eyes closed/open

5. Direction of falling

When observing gait

1. Gait

2.Stance

3.sitting

4.speech disturbance

5.finger chase

6.nose-finger

7. fast alternating hand movements

8. Heel to shin

SARA assessment items

1. Gait level surface

2. Change in gait speed

3. Gait with horizontal head turns

4. Gait with vertical head turns

5. Gait with pivot

6. Step over obstacle

7. Step around obstacles

8. Steps

DGI assessment items

1. Used to for teaching gentle movement exercises to increase precision to help patient perform everyday lift activities./

2. Progression = altering speed, breadth and complexity of exercises.

3. Begin at one of four positions: lying, kneeling, standing or walking

Frenkel exercises

1. Increase postural control of head, trunk and UL

2. Gait retraining

3. Increase coordination

Goals for treatment with Ataxia

Prone position, use pillows to prop up pt

Pt lifts head and holds position

Treatment for head control (ataxia)

1. Prop onto elbows, shift weight from shoulder to shoulder by alternating elbows.

2. Rhythmic stablisation in prone/propped

3. Gait belt + therabands peform sitting exercises in/out of BOS = decrease postural sway

Treatment for trunk control (ataxia)

1. Mat work - low CoG and large BOS

2. Functional tasks - bed mobility, transfers, supine to sidelying, sitting over side of bed

3. Positioning = prone --> sidelying --> four point kneeling --> moving arms single and alternatively

Treatment for sitting balance (ataxia)

1. Start proximal to distal + slow mvts

2. Recipricoal sequencing = cycling

3. PNF patterns + bands, weights and manual guidance

Treatment for UL (ataxia)

Frenkel exercises

Low level exercises

High level exercises

Treatment for coordination (ataxia)

1. Stepping and weight shifting in parallel bars

2. Parallel bars with manual guidance

3. Treadmill with partial body weight support

4. Joint approximation + theraband + gait belt

Treatment for gait (ataxia)

1. Static

2. Dynamic

3. Whole body mvts

4. Falls prevention practice

Treatment for balance (ataxia)

1. Extension of spine - prone lying , push up the shoulder girdle from prone

2. Rotation of the spine - supine lying, knee bent, rotate the knees to the right and left 3. Flexion of shoulder - supine lying, lift arms in the direction of head

Contracture prevention (ataxia)

Intoxication: alcohol, sedatives and anticonvulsants

Infections

Lyme disease

Hypothyroidism

Genetic disorder

High altitude cerebral oedema

Symmetrical ataxias

Stroke

Infections

Demyelination

Tumours

Trauma

AIDS

Cervical spondolysis

Asymmetrical ataxias

Damage to sensory pathways

Loss of proprioception and vibration sense

Broad based steppage gait and slapping foot contact

Dysarthria and nystagmus are rare

Sensory ataxia

Damage to VIII nerve or connections

Vertigo, nausea, loss of balance and nystagmus

Vestibular Ataxia

Damage to cerebellum or cerebral brainstem and SC connections

Sensory receptors in tact

↓ Proprioception = worse with increase speed

Wide-based gait with irregular and unsteady step

Cerebellar ataxia

Due to frontal lobe damage

Always has cognitive dysfunction, dementia, preservation

Frontal ataxia

Most caudal intact dermatome for both pin prick and light touch until the first segment with a score of less than two. Dermatome above impaired/absent is sensory level

Sensory level

Defined by the lowest key functioning myotome with at least grade 3 strength. Can differ from right to left.

Single ----- level would be the most rostal.

Motor level

Most caudal segment with intact motor, sensory and antigravity muscle strength (G3).

Single -------- level is the most rostral of 4 sides: left/right& sensory/motor

Neurological level

Only used with complete injuries, refers to the dermatomes and myotomes caudal to the sensory and motor levels that remain partially innervated.

Eg if partial innervation extends from C6-C8 --> C8 would be the ZPP.

Recorded both right and left.

Zone of partial preservation

no motor or sensory function preserved in S4/5

ASIA A : Complete

SENSORY but NOT motor function below neurological level but INCLUDES sacral segments (S4/5).

No motor function preserved more than three levels below the motor level on either side.

ASIA B: Sensory incomplete

MOTOR function is preserved below neurological level + MORE THAN HALF OF KEY MUSCLES have muscle strength of LESS than 3 (Grade 0-2)

ASIA C: Motor incomplete

Motor function is preserved below the neurological level and at least half or more of key muscle function below NLI have grade 3 strength or more

ASIA D: Motor incomplete

Sensation and motor function tested and graded as normal

ASIA E : Normal

occurs with injury above T1

Tetraplegia

injury at C1-C3 (ventilation required) and C4

High level tetraplegia

injury at C5-C8

Low level tetraplegia

occurs at T2 or below

Paraplegia

injury at T2-T6 (trunk and LL)

High level paraplegia

injury at T7 or below

Low level paraplegia

Toilet – Carer need, Shower commode chair with padded seat and tilt-in-space feature (head rest for C1-3).

Housekeeping – Carers needed for housekeeping

Eating – Carer/s needed, may be able to use mobile arm support (C4) with great effort/practice.

Positioning – Carers needed, power tilt-in-space wheelchair, pressure relief cushioning, postural support and head control systems, specialised bed and pressure relieving mattress. Hand splints for positioning and deformity control. Grooming – carers needed for grooming Bed mobility – Carers needed, physically dependent. Electric hi-lo bed with trendelenberg side rails and slide sheets. Mobility- Independent use. Power wheelchair with tilt-in-space feature, specialised positioning and control equipment (ventilator tray C1-C3)

Transport – Dependent, modified access van with locking system, accessible taxi Wheelchair transfer– Electric hoist with sling

Showering – Carer/s needed, shower commode chair with padded seat and tilt-in-space feature, handheld shower hose

C1-4 care requirements

Toilet – Carer need, Shower commode chair with padded seat and tilt-in-space feature (head rest for C1-3).

Housekeeping – Carers needed for housekeeping

Eating – Wrist extension splint, adaptive feeding equipment (palmer band). Assistance for set up then independent with aids

Positioning – Carers needed, power tilt-in-space wheelchair, pressure relief cushioning, postural support and head control systems, specialised bed and pressure relieving mattress. Hand splints for positioning and deformity control.

Grooming – Palmer bands/modified splints designed for these tasks. Assistance with set up, may be able to assist with upper body dressing

Bed mobility – Carers needed, physically dependent. Electric hi-lo bed with trendelenberg side rails and slide sheets. Mobility- Independent use. Power wheelchair with tilt-in-space feature, specialised positioning and control equipment (ventilator tray C1-C3)

Transport – Dependent, modified access van with locking system, accessible taxi Wheelchair transfer– Electric hoist with sling

Showering – Carer/s needed, shower commode chair with padded seat and tilt-in-space feature, handheld shower hose

C5 care requirements

Toileting - shower commode chair with padded seat. Independent or may require assistance

Housekeeping – assistance required

Eating – adaptive feeding equipment and techniques (palmer band/ringed cutlery). Assistance for set up then independent

Positioning – Power wheelchair may be required, pressure reliveing cushion, postural support equipment, pressure relieving mattress or mattress overlay. May be able to lift to relieve pressure Grooming/dressing - adaptive techniques and equipment, may need assistance to save time and energy

Bed mobility – Electric hi/lo bed. May be independent/dependent

Mobility – Ultra lightweight ridged or folding frame wheelchair w modified push rims. Power tilt-in-space wheelchair with hand control may be needed. ↑ strength need for push wheelchair, power w/chair needed for longer distance and outdoors

Transport – modified hand controls to drive, specilaised technique to transfer self and w/chair into vehicle, may require w/chair hoist on car roof. Independent with special modifications, may drive from wheelchair or vehicle seat.

Wheelchair transfer – electric hoist with sling may be required + sliding board. May be indepednet with sldiign board, may require assistance with hoist

Showering – shower commode chair with padded seat, handheld shower hose. Moderate to total assistance

C6 care requirements

Toileting – Independent, shower commode chair with padded seat and cut out for access

Housekeeping - assistance required for heavy cleaning, carrying and laundry etc Eating – Independent, use of palmer bands/ringed cutley

Positioning – Independent, pressure rleiveing cushion, postural support equipment, pressure relieve mattresses

Grooming/dressing – may use aids and adaptative techniques independently

Bed mobility – Independent, electric hi/lo bed

Mobility – Mostly independent. Ultra lightweight ridged or folding frame wheelchair. May need power w/chair

Transport – Independent driving from w/chair or vehicle seat. Modified hand controls to drive, may require w/chair hoist with folding w/chair.

Wheelchair transfer – Independent, with or without sliding board

Showering – Independent, shower commode with padded seat or chair without armrests – hand held shower

C7-8 care requirements

Toileting – Independent, shower commode chair w padded seat

Housekeeping – assistance may be required with heavy cleaning and inaccessible areas

Eating – Independent

Positioning – pressure relief cushion, postural support equipment as required, pressure relieving mattress or overlay Grooming/dressing - Independent with adaptive techniques

Bed mobility – Independent with king or large size bed

Mobility – Independent, ultra lightweight ridged or folding frame w/chair

Transport – Independent, modified hand controls to drive, adaptive technique to transfer seld and wheelchair into vehicle Wheelchair transfer – Independent, with or without sliding board

Showering – Independent, shower commode with padded seat or shower chair without arm rests, hand held shower hose

T-10-L1 care requirements

Toileting – Independent, padded toilet seat

Housekeeping – mostly independent, may require assistance

Eating – Independent

Positioning – Independent, pressure relieving cushion, postural support equipment

Grooming/dressing – Independent, adaptive techniques for lower limb dressing

Bed mobility – Independent, standard bed Mobility – Independent, ultra lieght w/chair or folding w/chair

Transport – Independent, modified hand controls to drive, adaptive techniques to transfer self and w/chair into vehicle, may require w/chair hoist on car roof. Wheelchair transfer – Independent, with or without sliding board

Showering – Independent, shower commode chair with padded seat, shower bench or shower chair – hand held shower hose

L1-L5 care requirements

noxious stimuli to the abdominal organs and lungs, dull ache, poorly localised, can cause referred pain. Can cause nausea, vomiting and changes in BP

Visceral pain

due to damage in peripheral nerves or CNS, occurs without any external stimuli, describing as burning, sharp and shooting pain

Neuropathic pain

pain no identifiable cause, may be far greater than pain with an identified cause

Idiopathic pain

pain arises from tendons, bones, fascia, joints, muscle and ligaments

Somatic pain

common occurrence with SCI more often with tetraplegia, caused by impingement, rotator cuff tear, capsulitis, instability and capsular contracture

Shoulder pain

Exaggerated sympathetic response usually to noxious stimulus below the lesion level. T6 or above

Dangerous ↑ BP ↑ICP = stroke or death.

Causes - bladder/renal, bowel, skin, fracture, infection, pain, sexual stimulation or pregnancy

Symptoms - severe headache, ↑ BP, pink/red blotchy rash above lesion, anxiety, snuffly sensation in frontal sinuses, bradycardia

Autonomic dysreflexia

BP management, locate and remove cause, anti-hypertensive agent (glycerile trinitrate), upright sitting ↓ ICP

Autonomic dysreflexia Mx

Cyst formation at the injury site, progression of the cyst up the spinal cord, results in loss of function and pain

Syringomyelia

Surgical procedures (drainage into peritoneal cavity) , decompressing the cyst cavity

Syringomyelia Mx

Swelling occurring in dependent limbs sometimes abdomen due to loss of vasomotor tone and lack of active movement

Oedema

Elevation of affected limb, use of compression stockings, range of movement exercises, massage

Oedema Mx

1/3 of bone lost may be lost in first 16 months, usually not above lesion

Occurs at lower rate for 3-8 years

Causes - decreased blood flow, venous stasis, tissue acidosis, hormonal changes, medications

OA

Regular screening, weight bearing exercises (walking, standing, fes cycling), calcium, bisphosphonates, calcitonin and vitamin D.

May reduce incidence by up to 50% of gen pop

OA Mx

Present in up to 80% of SCI

Only present in LMN

Usually occurs in first year post injury then plateaus

Spasticity (SCI)

Damage to reticulospinal and vestibulospinal tracts =

Flexor spasticity

Damage to dorsal reticulospinal tract =

Extensor spasticity

Maintain mm bulk, improve circulation, reduce swelling and help with functional and daily activities

Benefits of spasticity

AROM and PROM X's, splinting, standing (tilt table, frames etc), Baclofen, Dantroleme sodium

Spasticity Mx (SCI)

Muscle shortening and joint capsule contract

Occurs with unopposed muscle action/spasticity

Muscle contractures

Correct positioning in wheelchair and bed, daily stretches, controlling spasticity, splinting and exercises

Muscle contractures Mx (SCI)

Loss of muscular control and poor posture contribute to development of problems - breathing functional activities and pain

Spinal deformity

Correct, supported positioning in w/chair and bed, bracing, strengthening, education and surgery

Spinal deformity Mx

Circulation changes due to vasomotor tone and altered autonomic function, blood pooling in abdomen and lower limbs resulting in dizziness, fainting or blacking out

Postural hypotension (SCI)

Sit person up gradually from lying, tilt table gradually increase incline, TED stockings, abdominal binders, monitor BP and client response

Postural hypotension Mx

Body temperature is maintained by several mechanisms - shivering, vasoconstriction of blood vessels in skin to conserve heat, dilation of skin blood vessels (cooling) and sweating

People with injuries above T6 lose ability to shiver/sweat disconnection between the thalamus thermoregulating mechanism

Poikilothermia