Neurological Physiotherapy FINALS

What are the Essential Components of standing up?

• Initial foot placement with ankles in dorsiflexion

• Forward inclination of the trunk with trunk extended (hip flexion)

• Anterior translation of the knees (ankle D/Fl)

• Knee, hip and ankle extension

What are Common Kinematic Deviations for Standing Up?

• Decreased ankle dorsiflexion

• Decreased forward inclination during stand up (decreased hip flexion)

• Decreased weight bearing on affected leg during stand up

• Decreased hip extension in final standing alignment.

• Decreased knee extension in final standing alignment.

How do you train initial foot placement (addressing the KD decreased ankle dorsiflexion) during sit to stand (STS)?

Note: There’s a part and whole task practice component.

The part task practice of moving into ankle dorsiflexion and knee flexion.

The whole task practice of doing the foot positioning prior to standing up.

What is the Environment Set-Up for the part task practice of initial foot placement (addressing the KD decreased ankle dorsiflexion) during sit to stand (STS)?

• Sitting well supported

• Slide sheet/ skateboard if required to decrease difficulty

• Affected UL in sling if indicated

Visual/tactile Cues to Endpoint of Movement

• Blocks

Cue to Prevent Compensatory Movements

• Trunk flexion

What is the Communication for the part task practice of initial foot placement (addressing the KD decreased ankle dorsiflexion) during sit to stand (STS)?

• Explanation to patient of role of initial foot placement

Instructions

• Touch the marker with your foot

• Instruct how to avoid compensations

KP

• Reaching markers

KR

• Successful attempts/Reps recorded

• Time taken

• Distance moved

• Amount of resistance

What is the Manual Guidance for the part task practice of initial foot placement (addressing the KD decreased ankle dorsiflexion) during sit to stand (STS)?

MG to demonstrate movement

How can you Increase Difficulty for the part task practice of initial foot placement (addressing the KD decreased ankle dorsiflexion) during sit to stand (STS)?

• Increase ROM

• Remove slidesheet

What is the Environment Set-Up for the whole task practice of initial foot placement (addressing the KD decreased ankle dorsiflexion) during sit to stand (STS)?

• Moving feet into appropriate foot position followed by stand up

• Visual/ tactile cue for correct foot placement

What is the Communication for the whole task practice of initial foot placement (addressing the KD decreased ankle dorsiflexion) during sit to stand (STS)?

• Explanation to the patient of the role of initial foot placement

Instructions

• Touch the marker with your foot then stand up

KP

• Reaching markers

KR

• Successful attempts

• Time taken

• Seat height

What is the Manual Guidance for the whole task practice of initial foot placement (addressing the KD decreased ankle dorsiflexion) during sit to stand (STS)?

Assistance if required

How can you Increase Difficulty for the whole task practice of initial foot placement (addressing the KD decreased ankle dorsiflexion) during sit to stand (STS)?

• Lower seat height

• Unaffected foot in front

• Remove visual cues

How do you train forward inclination of the trunk (addressing the KD decreased forward inclination/hip flexion) during sit to stand (STS)?

Note: There’s a part and whole task practice component.

The part task practice of moving trunk forward quickly (so shoulders over knees).

The whole task practice of performing the forward inclination of the trunk prior to standing up.

What is the Environment Set-Up for the part task practice of forward inclination of the trunk (addressing the KD decreased forward inclination/hip flexion) during sit to stand (STS)?

• Sitting with table in front as object to reach to.

• Table needs to be far enough away that the shoulders are coming over the knees

• Feet on ground, heels behind knees

• Affected UL in sling if indicated

Cue to endpoint of movement

• Table/object

Cue to prevent compensatory movements

• Trunk rotation

How to train loading of affected leg (addressing decreased weight bearing on affected leg)?

Part task practice sitting and reaching to the affected side to increase weight bearing on the affected lower limb.

How to train loading of affected leg in standing up as a whole task practice?

Positioning the intact side close against a wall, using markers for foot placement.

How to provide assistance at the affected leg during standing up training?

Therapist hands on affected leg at ischial tuberosity and anteriorly above the knee, assisting affected leg to extend as patient stands up.

How to provide assistance at the shoulder girdle during standing up training?

One therapist at front with hands around patient’s scapulae, assisting forward movement to the edge of the chair if required.

What are the essential components of sitting?

Head and trunk erect, shoulders over the hips, weight evenly distributed, and ability to reach beyond arm’s length and return to vertical.

What are common kinematic deviations during sitting?

Decreased ankle dorsiflexion and knee flexion, decreased weight bearing through affected side, inability to maintain erect trunk, and decreased ability to reach to affected side and return to vertical.

How to train an erect trunk (addressing inability to maintain erect trunk) during sitting?

Sitting intact side against wall, using a visual marker, and providing manual guidance at the knee and shoulder.

How to train even weight distribution (addressing decreased weight bearing through affected side) during sitting?

Sitting, reaching to affected side, using scales/limb load monitor for feedback, and providing manual guidance at the knee.

How to train reaching beyond arm's length (addressing decreased ability to reach to affected side) during sitting?

Ensuring affected leg is in correct position, using markers on a table at 120% of arm's length, and scales/limb load monitor for feedback.

What are the essential components of standing?

Head and trunk erect, hip and knee extension, hips anterior to ankles, weight evenly distributed, and ability to reach beyond arm’s length and return to vertical.

What are common kinematic deviations during standing?

Falling to affected side, decreased weight bearing, decreased hip extension, decreased knee extension, and decreased ability to reach to affected side.

How to train maintaining an erect trunk during standing?

Patient standing with wall on intact side, using marker on wall, and providing manual guidance to assist hip and knee extension.

How to train even weight distribution during standing?

Patient standing, shifting pelvis to affected side, using scales for feedback, and therapist providing manual guidance at knee and pelvis.

How to train hip extension during standing?

Patient standing, using a cue to hip extension, and therapist providing manual guidance at pelvis.

How to train knee extension during standing?

Patient standing, using a cue to knee extension, and therapist providing manual guidance for knee extension.

How to train reaching to the affected side and returning to vertical during standing?

Patient standing, reaching with hip movement, therapist providing manual guidance at pelvis and knee.

What are the abbreviations for phases of walking?

Initial contact/heel strike (IC), foot flat/loading response (FF), mid stance (MS), heel off/terminal stance (HO), toe off/pre-swing (TO), early swing (ES), mid swing (MS), late swing (LS).

What are common kinematic deviations during walking?

Decreased ankle dorsiflexion/hip extension, decreased knee extension, knee hyperextension, decreased ankle plantar flexion, decreased/increased hip adduction, decreased ankle dorsiflexion in swing, decreased knee flexion, decreased hip flexion in swing.

How to train ankle dorsiflexion/hip extension MS to HO during walking?

Patient standing with feet together, therapist on affected side, using markers for step length.

How to train ankle dorsiflexion/hip extension MS to HO as a whole practice?

Walking with visual/auditory cues to increase step length, using markers, and treadmill.

How to train knee extension or decreasing hyper-extension during stance during walking?

Patient standing with back to wall, therapist providing movement guidance.

How to train knee extension or decreasing hyperextension during stance, whole practice?

Walking with MG at knee / verbal cues, may trial knee strapping if patient has sensory loss

How to train ankle plantar flexion at end of stance during walking?

Patient standing back to wall, therapist providing movement guidance.

How to train ankle plantar flexion at end of stance during walking as a whole practice?

Walking with visual cues for step length/auditory cues on treadmill.

How to train control of lateral pelvic shift in stance during walking?

Patient stepping intact foot forward, therapist providing movement guidance.

How to train control of lateral pelvic shift as a whole practice?

Walking with visual cues for BOS width.

How to train ankle dorsiflexion during swing phase?

Patient standing in step stance, therapist guiding movement

How to train ankle dorsiflexion during swing phase during whole practice?

Walking overground with markers for step length

How to train hip flexion/knee flexion in early to mid-swing during walking??

Patient is standing with block in front of feet, counter cues for movement

How to train hip flexion/knee flexion in early to mid-swing during whole practice for walking.

Walking overground and treadmill with specific cues

How to facilitate Assisted walking?

Two therapists assisting with clear environment, improve walking.

What strategies can be employed to improve walking patterns of people who can walk without assistance.

Visual and auditory cues with overground walking to assist with improve walking pattern.

What are the essential components of reaching and manipulation?

Shoulder forward flexion, abduction, external rotation, elbow flexion/extension, forearm supination/pronation, wrist extension/radial/ulnar deviation, thumb abduction/conjoint rotation, MCP an IP flexion/extension, opposition.

What are common kinematic deviations during reaching?

Decreased shoulder forward flexion, shoulder external rotation, elbow extension, and forearm supination.

What are common kinematic deviations during manipulation?

Decreased wrist extension, thumb abduction and conjoint rotation, MCP flexion/extension, opposition of 4th and 5th fingers, force modulation/individuation of fingers.

Describe Shoulder forward flexion Training during practice?

Pt standing near wall, paper taped ,w forearm supinated to ensure ER of shoulder

Describe Shoulder forward flexion Traning as whole practice??

reach and grasp using objects that require ER eg. cup of water

How to train shoulder external rotation in part practice?

Moving objects to outside of body, object between arm and body to reduce shoulder abduction.

Describe Shoulder external rotation Whole Practice

Reach and grasp activities using objects that require external rotation (cup of water) and restraining trunk

NB – this strategy could be used for shoulder forward flexion as well as elbow extension Explain how to do Part practice reach for this

Reach to touch an object with trunk kept against chair during Elbow extension

NB – Whole practice Reach and grasp activities with ELBOW EXTENSION

Reach and Grasp activities, counter act trunk flexion to promote elbow extension and over all flexion

Forearm supination (decreased forearm supination) what doe part task practice include?

Moving forearm into supination to move objects.

Whole practice Reach and grasp activities explain which objects that require supination?

Reach and grasp activity use object that require supination to engage in this motion.

Wrist extension and radial deviation?

Describe Radian deviation with writst extension and Wrist ext/flex with wrist in radial deviation

Whole practice Wrist extrension

Which Activities requiring wrist extension/ RD should be promoted?

Part practice Thumb abduction and conjoint rotation describe the part practice and equipment

Thumb opposition /conjoint rotation and you can add a small ball to promote this more

What should you do in the whole practice for Thumb abduction and conjoint rotation

Whole practice Practice picking up objects with thumb abduction and conjoint rotation

Describe Ext of MCP joints

Patient is sitting and opens hand

Describe Whole practice, Flex/ ext of MCP joints with IP joints in some flexion?

Patient is sitting and grasping things this will promote better flex of the hand

Part Practice - Conjoint rotation of 4th/5th fingers cupping of hand ?

Patient can take to the pad of thumb to other fingers

Whole practice - Conjoint rotation of 4th/5th fingers cupping of hand?

Patient can use whole hand to pour water in there hand

Force through 2nd finger with IP joints in extension, descibe part pratice

Fork in the had

Force through 2nd finger with IP joints in extension, descibe Whole Practice

Use cutlery or tape to position finger correctly

Modification of force between thumb and fingers (Decreased force modulation when gripping objects) describe part task

The Peg Game

What do you do in whole practice?

Patient can Manipulating objects that provide some feedback about the amount of force being applied to them e.g. - polystyrene cups - bottle of water - using tweezers to pick up small objects

What do you do in the prat practice?

Patient can take Forearm support and is able to tapp ther fingers and what more do you do?

Decrive a whole practice activity

Patient picking up all objects while palming