PPC tut 11a

Impairment Assessment and Clinical Findings

• General Impairments Identified:

  • Reduced strength (weakness) on both sides.
  • Reduced Range of Motion (ROM).
  • Decreased coordination, primarily affecting the right side of the body.

• Muscle Tone and Spasticity (Tardieu Scale Analysis):

  • The group examined the Tardieu scores for Mr. John, focusing on degrees of movement at different velocities.
  • The Tardieu Scale Scoring Reference:
  • $0$: No resistance throughout the passive movement.
  • $1$: Slight resistance throughout the passive movement with no clear catch.
  • $2$: Clear catch at a precise angle, interrupting the passive movement, followed by release.
  • $3$: Fatigable clonus ($< 10$ seconds) occurring at a precise angle.
  • $4$: Infatigable clonus ($> 10$ seconds) occurring at a precise angle.
  • Clinical Application to Mr. John:
  • The quality of muscle reaction ($X$) was recorded as $1$ at velocity $V_1$ (slow) and $3$ at velocity $V_3$ (fast).
  • This change in score ($X=1$ to $X=3$) confirms the presence of spasticity, as the resistance is velocity-dependent.

• Comparison of Dorsiflexion (Right vs. Left):

  • Right Dorsiflexion: Measured at $7^{\circ}$. There is no contracture present, though the group noted this score highlights a relative deficit.
  • Left Dorsiflexion: Measured at $-3^{\circ}$.
  • The negative value ($-3^{\circ}$) indicates the ankle is resting in a plantarflexed position and cannot reach neutral ($0^{\circ}$).
  • Because the degree of range ($-3^{\circ}$) remained the same across three different velocities ($V_1$, $V_2$, and $V_3$), it indicates a contracture rather than just a dynamic spastic catch.
  • There was a lack of strength noted on the left, leading to it resting in "slight planta" (plantarflexion).

Activity Limitations and Discharge Status

• Activity Limitations on Admission:

  • Difficulty with walking and running.
  • Balance issues.
  • Difficulty with sit-to-stand transitions and standing for long periods.
  • Sitting balance was impaired, though he was not planning to sit on the floor.
  • Primary Contributing Factor: The group agreed that weakness was the most significant impairment contributing to these limitations.

• Status at Discharge:

  • Sitting Balance: Fully independent in all aspects of sitting balance.
  • Reaching: Able to reach out to $920\%$ (as transcribed) or $20\%$ of arm's length in all directions from a seat height of $43\,cm$ with no loss of balance.
  • Weight Bearing: Achieving relatively even weight bearing through both limbs.
  • 6-Minute Walk Test (6MWT): Mr. John achieved a distance of $457\,m$ at discharge.
  • Gait Analysis: Continued to show some kinetic deviations and reduced symmetry/coordination. He was able to walk safely using handrails.

High-Level Mobility and Running Analysis

• Running Mechanics:

  • Flight Phase: Defined as the moment during running when both feet are simultaneously off the ground. Mr. John was unable to achieve a flight phase during his running assessment.
  • Swing Phase Issues: Displayed reduced reciprocal arm swing bilaterally.
  • Knee Stabilization: Reduced "right knee yield" when landing on the right leg. The leg appeared stiff, which prevented the necessary "bounce" for efficient running movement.
  • Hip and Ankle Mechanics: He demonstrated insufficient hip hiking and poor ankle dorsiflexion/plantarflexion to push back effectively.

• High-Level Mobility Assessment (HiMAT):

  • Tasks discussed include stair ascending and descending.
  • Testing included squatting and single-leg plantarflexion (calf raises/toe walking).
  • Observations during stride: He was shortening his stride and pushing off from the left leg, while the right side showed weakness in coordination, with the right foot just "touching and going."

Intervention and Training Strategies

• Whole vs. Part Practice:

  • The group debated whether to use "whole practice" (practicing the entire gait/run) or "part practice" (drilling specific components like ankle dorsiflexion).
  • Argument for Part Practice: If the participant cannot coordinate the movement as a whole due to specific deficits (poor ankle and hip flexion), whole practice may not be effective.
  • Argument for Whole Practice/Functional Training: There is a need to maintain functionality. However, the tutor noted that if you want to change a habit (like a compensation), you must drill a new habit to override the old one.

• Specific Exercise Ideas:

  • Treadmill Training: Using manual guided stepping on a treadmill to facilitate gait.
  • Rhythm and Timing: Utilizing metronome-based training to assist with cadence.
  • Targeted Strengthening: Focusing on dorsiflexion strength and range of motion.
  • High-Level Tasks: "Elevated single leg plantarflexion" and "toe walking" were mentioned as advanced mobility drills.

Questions & Discussion

• Student: "Would you get specific… about these problems in gait and stuff? Like these plantarflexion and step length and all that. Would that fall under that?"

• Tutor: "Yes. Exactly. Because I need to know. That's good."

• Student: "Does a negative three mean less than?"

• Tutor: "Less of dorsiflexion. So on the left… it's resting in [plantarflexion]."

• Student: "Why are you doing part practice if they're already walking?"

• Student/Group: Discussed that for habit change, specific drills are necessary to ensure the new motor pattern overrides the old compensatory habit.