Additional Rehab Components – Semester IV: PTA 202 Rehab II

Course Objectives

Objective #14: Implement and adjust interventions for common neurological conditions following the licensed physical therapist’s plan of care.
Objectives #20 \rightarrow #27: Accurately review health records prior to treatment, recognize contraindications/precautions, and safely carry out the prescribed plan of care.

Patient Positioning

General Rationale

Correct positioning ↓ secondary impairments (contractures, pressure injury, malalignment).
Promotes circulation, optimizes sensory input, and sets a foundation for functional movement.

Supine Position (more-affected side emphasized)

Head/Neck: Neutral, symmetrical, pillow support.
Trunk: Midline alignment.
More-affected UE
• Scapula protracted, shoulder forward/slight ABD
• Elbow extended, forearm neutral, hand resting on pillow
• Wrist neutral, fingers extended, thumb ABD (resting splint PRN)
More-affected LE
• Hip forward (pelvic protraction)
• Knee supported on small pillow/towel roll to prevent hyperextension
• Nothing touching soles; persistent plantarflexion ⇒ neutral-position splint

Side-Lying on Less-Affected Side

Head/Neck: Neutral.
Trunk: Midline; small pillow/towel under rib cage to elongate hemiplegic side.
More-affected UE: Scapular protraction, shoulder forward; arm on pillow in elbow extension, wrist neutral, fingers extended, thumb ABD.
More-affected LE: Hip forward & flexed, knee flexed, entire limb supported on pillow.

Side-Lying on More-Affected Side

Head/Neck: Neutral.
Trunk: Midline.
More-affected UE:
• Scapula protracted, shoulder forward
• Arm placed in slight ABD & ER, elbow extended
• Forearm supinated, wrist neutral, fingers extended, thumb ABD
More-affected LE: Two options
1. Hip extended, knee flexed with pillow support
2. Slight hip/knee flexion coupled with pelvic protraction

Sitting (Armchair or Wheelchair)

Head/Neck: Neutral, directly above pelvis.
Trunk: Spine extension.
Pelvis: Neutral; equal weight-bearing through both ischial tuberosities.
More-affected UE:
• Shoulder protracted & forward
• Elbow, forearm supported on arm trough/lapboard
• Wrist neutral, fingers extended, thumb ABD (resting splint if needed)

Visual Reinforcement (Stroke Foundation Diagrams)

Emphasizes:
• Feet flat, equal buttock weight, shoulder/pelvic girdles forward in sitting
• Pillows to protect shoulder/scapular alignment in side-lying
• Arm positioning palm-up to avoid impingement
• Affected LE flexed & supported to reduce hip/knee extensor tone

Pharmacological Management

Antiepileptic Agents

Action: ↓ / eliminate aberrant cortical discharge ⇒ seizure control.
Indications: Epilepsy, post-traumatic seizure prophylaxis.
Side-Effects: Ataxia, dermatologic reactions, behavior change, GI distress, HA, blurred vision, weight gain, somnolence, depressed mood.
PT Implications:
• Know seizure first-aid/911 criteria.
• Patients may be light/noise sensitive ⇒ adjust clinic.
Examples: Dilantin, Tegretol, Phenobarbital.

Antispasticity Agents

Action: Promote relaxation of spastic muscle (exaggerated stretch reflex after CNS injury).
Indications: ↑ tone due to SCI, CVA, MS, etc.
Side-Effects: Drowsiness, confusion, dizziness, HA, muscle weakness, tolerance, dependence.
PT Implications:
• Balance ↓ tone with need for active strength.
• Sedation may mandate shorter or differently timed sessions.
• Emphasize handling/facilitation & strengthening to foster function.
Examples: Baclofen, Dantrium.

Dopamine Replacement Agents

Action: Cross blood–brain barrier via active transport → convert to dopamine → ↓ PD motor symptoms.
Indications: Parkinson’s disease, parkinsonism.
Side-Effects: Arrhythmias (levodopa), GI upset, orthostatic hypotension, dyskinesias, mood/behavioral change.
PT Implications:
• Schedule therapy ≈ $1\ \text{hr}$ post-dose for peak benefit.
• Monitor BP; guard against fall risk.
• Understand effects of “drug holiday.”
Examples: Sinemet, Madopar; others: Ropinirole, Rasagiline, Tolcapone, Amantadine.

Muscle Relaxant Agents

Action: ↓ tonic muscle spasm (musculoskeletal/peripheral origin, not CNS spasticity).
Indications: Acute muscle spasm, strain, peripheral nerve irritation.
Side-Effects: Drowsiness, dizziness, N/V, HA, sedation, tolerance, dependence.
PT Implications:
• Prevent re-injury via stretching, posture training, HEP.
• Educate on safe body mechanics when medicated.
Examples: Valium, Flexeril.

Medical Procedures & Testing for Neurological Dysfunction

Cerebral Angiography (invasive)
• Catheter + contrast dye + serial x-rays to visualize cerebral vasculature; detects aneurysm, AVM, stenosis.
Computed Tomography (CT)
• Sequential x-ray “slices,” excellent for acute hemorrhage, bone; may use IV contrast for vasculature/tumor.
Discography (invasive)
• CT + contrast injected into intervertebral disc to evaluate discogenic pain.
Electroencephalography (EEG)
• Surface electrodes record electrical brain activity; identifies seizure foci, sleep disorders.
Electromyography (EMG, invasive)
• Needle electrodes assess motor unit recruitment; dx neuropathy, radiculopathy, ALS.
Nerve Conduction Velocity (NCV)
• Surface stimulation measures peripheral nerve speed/amplitude; localizes entrapment.
Magnetic Resonance Imaging (MRI)
• High-resolution tissue contrast via magnetic fields; gadolinium contrast can highlight inflammation, tumors.
Myelography (invasive)
• Contrast dye into CSF with x-ray/CT to image spinal canal, NR, cord; useful when MRI contraindicated.
Positron Emission Tomography (PET, invasive)
• Radioactive tracer maps metabolic activity → tumor grading, PD, dementia.
Spinal Puncture (Lumbar Tap)
• Needle between $L3$ – $L4$ to sample CSF; dx infection, MS, subarachnoid hemorrhage; may measure opening pressure.

Synergy Patterns After Hemiplegia

Upper Extremity (UE)

Flexion Synergy (often dominant):
• Scapular retraction/elevation or hyper-extension
• Shoulder ABD, ER
• Elbow flexion (strongest)
• Forearm supination
• Wrist & finger flexion
Extension Synergy:
• Scapular protraction
• Shoulder ADD (strongest), IR
• Elbow extension
• Forearm pronation (strong)
• Wrist & finger flexion

Lower Extremity (LE)

Flexion Synergy:
• Hip flexion (strongest), ABD, ER
• Knee flexion
• Ankle DF, inversion
• Toe DF
Extension Synergy (often dominant):
• Hip extension, ADD (strongest), IR
• Knee extension (strongest)
• Ankle PF (strong), inversion
• Toe PF

Clinical Significance

Knowledge of patterning guides PNF techniques, neurofacilitation, orthotic prescription, & tone-inhibiting positioning.
Treatment aims: promote selective movement outside of obligatory synergies.

Practical / Ethical Considerations

Monitor vitals & cognition when patients are on CNS-active drugs; obtain informed consent for invasive diagnostics.
Prevent skin breakdown via diligent positioning; uphold patient dignity when manipulating limbs.
Maintain interprofessional communication—PTA must confirm the latest MD orders & nursing notes before treatment.

Connections to Foundational Principles

Positioning follows Brunnstrom & Bobath/NDT concepts of reflex-inhibiting postures.
Synergy awareness aligns with motor-control frameworks (dynamic systems, task-oriented training).
Pharmacology content links to prior semesters’ physiology (neurotransmitter function, blood–brain barrier transport).

Quick Reference Numerical / Statistical Points

Therapeutic scheduling: $1\ \text{hr}$ post-dopaminergic medication for optimal PD motor performance.
Lumbar puncture performed typically between vertebral levels $L3$ – $L4$ , below spinal cord termination.

Study Tips & Clinician Pearls

Rehearse supine → sit transfers maintaining the described limb positions to embody correct handling.
Make flashcards pairing each drug class with action / side-effect / PT implication.
Sketch the flexion vs. extension synergies; color-code strongest components.
During labs, palpate scapular & pelvic protraction to internalize positioning cues.