Adult Clinical Populations Flashcards
what is ankylosing spondylitis?
- inflammatory disease of spine and SI joints
- early - chronic pain
- late - new bone/spine segments fuse
what are the spinal changes in ankylosing spondylitis?
- loss of lumbar lordosis
- increased thoracic kyphosis
- head protraction
- loss of spinal flexibility in all planes
- hip flexion
what is the resulting posture for patients with ankylosing spondylitis?
- forward shift COM
- lowering COG
- accommodate knee flexion and PPT to maintain balance
what is the change in SSPC with ankylosing spondylitis?
- COP net displacement greater than controls
- frontal plane > sagittal plane (*sway more)
- 50% increase w/ eyes closed (* somatosensory/vestibular issue)
what are the changes in anticipatory and compensatory postural control with ankylosing spondylitis?
- limited postural control data available
- some data reveals:
– changes on static and dynamic clinical tools that worsens with disease severity
– confirms worse performance w/ eyes closed
– confirms higher incidence of dizziness vs controls
– impact on dynamic activities such as gait
what are some peripheral and central vestibular disorders?
peripheral
- BPPV
- unilateral vestibular hypofunction
- bilateral vestibular hypofunction
central
- stroke
- multiple sclerosis
- brain injury
what are the changes in information processing in vestibular disorders?
inaccurate vestibular input
- need to learn to select accurate input and ignore inaccurate input
decreased vestibular input
- need to rely heavily on remaining inputs
– somatosensory
– vision
how do vestibular disorders affect SSPC?
- screen for vestibular dysfunction using clinical test of sensory interaction and balance (CTSIB)
- inc sway/loss of balance when altering visual and somatosensory input
how do vestibular disorders affect APC?
- dec balance w/ dynamic movements that stimulate vestibular system
- head turns, bending, turning around, scanning environment
how do vestibular disorders affect RPC?
- use ankle strategy but not hip strategy even when hip strategy is required for postural stability
- i.e. standing on one foot, narrow beam, or in a heel-toe stance
what is Alzheimer’s disease?
- progressive disease process typically causing dementia
- characterized by slow decline/change in:
– memory
– language
– visuospatial skills
– personality
– cognition
what is the pathophysiology of Alzheimer’s disease?
- breakdown in processes necessary to sustain brain cells
- neuropathologic hallmarks
– amyloid plaques
– neurofibrally tangles - loss of neurons and synapses in cerebral cortex and subcortical regions –> atrophy
what are the changes in information processing in Alzheimer’s disease?
- slower reaction times
- impaired choice reaction time (dec focused attention)
- dec ability to use advanced cues to anticipate
- dec ability to inhibit non-regulatory stimuli
what are the changes in attention in Alzheimer’s disease?
- poor selective and divided attention
- dec performance on dual tasks
– no training improvement
– associated w/ risk of falls
what are the changes in SSPC and APC in Alzheimer’s disease?
- SSPC
– dec control of sway - dec performance w/ eyes closed
- APC
– reduced limits of stability and functional reach
– postural instability associated w/ dual task activity
what are the changes in memory in Alzheimer’s disease?
- early impairments in
– working memory
– episodic memory
– semantic memory - relative sparing of
– procedural memory
what are the appropriate strategies to use for motor learning for Alzheimer’s disease?
both implicit and explicit learning strategies can be used but reduced learning
- repeated practice (implicit)
- observational and guided learning (explicit)
– observational learning (demonstration) better than guided learning
– mental effort
– errorless learning (* learn mistakes if practiced, don’t learn from mistakes –> don’t correct)
practice should be constant, specific to task, and avoiding random with visual feedback being key
what is stroke?
- disruption of blood flow to area of CNS
- functional implications dependent upon brain regions involved:
– sensation
– motor
– cognition
– speech/language
– vision
what are the changes in information processing with stroke?
decreased sensory input
- homonymous hemianopia
- vestibular (brainstem)
- somatosensory loss associated with loss of function/prognosis
what are the changes in attention in stroke?
- R hemisphere lesions (frontoparietal)
– hemineglect/extinction
– dec ability to sustain, divide, and shift attention
what are the changes in motor control associated with stroke?
- tone – spasticity (UMN)
- abnormal synergies
– massed patterns of movement
– unable to selectively activate individual muscles
– results from increased recruitment of brainstem pathways
– typically UE flx>ext, LE ext>flx
what are the issues in SSPC in stroke?
- impairments in sitting and standing
- asymmetrical alignment
- increased and asymmetrical swag
what are the issues in APC in stroke?
- lesions to many areas can impair APC
– motor cortex, basal ganglia, cerebellum - delayed and reduced muscle activity in trunk on affected side
- external trunk support can improve performance
what are the changes in RPC in stroke?
- in-place strategies:
– impaired sequencing, timing, and amplitude in paretic limb in response to perturbation
– compensate for delays in distal muscles of paretic limb w/ early proximal activation of non-paretic limb - stepping strategies:
– similar time to foot off paretic vs non-paretic, however different pattern based on asymmetrical load
– delayed in non-paretic, but not paretic stepping are associated w/ falls
what are the changes in memory with stroke?
- dependent upon lesion location
- possible impairments:
– dec STM
– dec LTM
what are the changes in motor learning with stroke?
- explicit learning impaired with medial temporal lobe damage
- implicit learning distributed b/n brain structures so that no single lesion completely eliminates
- ideal practice conditions depend upon type of stroke
– MCA and basal ganglia stroke: explicit instruction dec learning
– cerebellar stroke: explicit instruction inc learning - learned non-use
what is Parkinson’s disease?
- progressive disorder of CNS
- loss of dopamine producing neurons in substatia nigra of the basal ganglia
- hypokinetic movement disorder
what are the changes in information processing in Parkinson’s disease?
- difficulty adapting to sudden environmental changes
- difficulty organizing and selecting sensory information
what are the changes in attention in Parkinson’s disease?
- difficulty selecting what sensory cues to attend to
- benefit from attentional curing
- dec performance under dual task conditions relative to control subjects
what are the changes in motor control with Parkinson’s disease?
- bradykinesia - slow movement time
- hypokinesia - dec movement amplitude
- akinesia - dec movement initiation
- rigidity
-tremor - secondary impairments:
– dec ROM (flexors)
– weakening (extensors)
what are the changes in SSPC with Parkinson’s disease?
- alignment
– stooped posture - swag
– inc sway area and velocity
– medication/DBS dec sway (conflicting evidence if meds induce dyskinesia)
what are the changes in APC in Parkinson’s disease?
- smaller anticipatory adjustments
- dec velocity
what are the changes in RPC in Parkinson’s disease?
- in place responses
– abnormal co-contraction of hip and knee musculature
– dec adaptation of postural strategies to environmental and task demands - stepping strategies
– dec weight shift prior to stepping
– slower to initiate step
– multiple small steps to recover balance
– inc risk of falls
what are the changes in memory in Parkinson’s disease?
- working memory
– dec relative to controls
– worsens w/ disease progression
– improves w/ dopamine - long term
– dec encoding
– dec retrieval
what are the changes in motor learning with Parkinson’s disease?
- slower rate of learning
- worsens w/ disease progression
- difficulty learning sequential tasks
- blocked practice improved acquisition and retention
- external focus of attention improves performance and motor learning
- cueing (auditory or visual) can improve performance
what are some causes of cerebellar pathology?
- multiple sclerosis
- stroke
- tumor
- brain injury
- cerebral palsy
- neurodegenerative conditions
- genetic conditions
- alcohol abuse
what are the changes in information processing with cerebellar pathology?
- dec ability to subconsciously compare sensory information to intended motor output
- dec ability to subconsciously respond to sensory feedback
- slower to respond to unexpected sensory info
what are the changes in attention with cerebellar pathology?
- must rely more on conscious, attention demanding pathways for movement adaptation
- performance may deteriorate with demands on attention
– dual task, fatigue, distraction
what are the changes in motor control with cerebellar pathology?
- hypotonia
- dec coordination/ataxia
– impaired timing and grading of muscles contractions: dysmetria, dysdiadochokinesia, decomposition of movement, “rebound” phenomenon - intention tremor
- improved control of isolated joint vs multipoint movement (not fluid; would move shoulder then elbow then wrist to pick up a cup for example)
what are the changes in SSPC in cerebellar pathology?
- inc postural sway
- direction of sway linked to lesion location
- wide BOS
– sway inc as BOS dec - vision/somatosensory input dec sway
what are the changes in APC with cerebellar pathology?
- able to demonstrate anticipatory adjustments but:
– abnormal timing
– mismatched scaling - dec ability to develop new anticipatory postural adjustments for novel tasks
what are the changes in RPC in cerebellar pathology?
- in place responses
– dec ability to grade force of output to match perturbation
– hypermetric postural response (larger amplitude and longer duration) - excessive compensatory sway opposite direction (body oscillations)
- stepping responses
– able to demonstrate stepping responses
– may require more than one step (* bc misplaced foot and are fixing it)
what are the changes in memory with cerebellar pathology?
- dec verbal working memory
- dec flexibility in previously acquired procedural memories
- dec consolidation of new procedural memories
what are the changes in motor learning with cerebellar pathology?
-cerebellum plays essential role in error correction
– practice dependent motor adaptation and learning
damage to cerebellum
– dec extent and rate of -adaptation of movement
–dec error based learning
– declarative learning intact
– limited ability to consolidate new skills (dec automaticity)
what practice and feedback strategies should be used for motor learning with cerebellar pathology
practice
- avoid trial and error learning
- stepwise movement repetition with verbal prompts to ensure conscious awareness
- require longer duration, inc repetitions, inc intensity
- massed
- less retention
feedback
- respond well to verbal cues to direct attention
- teach pts to consciously attend to movement
- providing KP and/or KR assists w/ error detection
- intermittent better than constant
what is Huntingtons disease?
- hyperkinetic disorder of the basal ganglia
- clinical sx:
– progressive movement disorder
– cognitive deficits
– behavioral changes
what are the changes in information processing with Huntingtons disease?
- slow response times
- difficulty selecting between relevant and irrelevant stimuli
- problems w/ visuospatial awareness
- difficulty inhibiting inappropriate responses
- difficulty anticipating due to overestimating abilities
what are the changes to memory in Huntingtons disease?
- dec ability to shift attention
- dec ability to concentrate on more than one task
what are the changes in motor control with Huntingtons disease?
- hypotonia
- chorea
– irregular, rapid, jerky, involuntary movements - overtime
– weakness
– decreased ROM - step length discrepancies and inconstancies
what are the changes in APC in Huntingtons disease?
- reduced limits of stability, even in pre-manifest HD
- limb movements deviate significantly from planned trajectories
- difficult to anticipate –> end up relying on reactive postural control
- may score very low on balance measures, but do not experience falls at as high a rate as typical older adults w/ similar scores
what are the memory changes in Huntingtons disease?
- difficulty retrieving memories
– applies to both distant and recent memories
what are the changes in motor learning in Huntingtons disease?
- better w/ part practice
- need inc guidance to put the [arts together
- avoid distractions and dual task
what are spinal cord injuries?
- can be categorized as
– traumatic v nontraumatic
– complete vs incomplete
– tetraplegia vs paraplegia - results in:
– reduced or absent sensory info from below the level of lesion - reduced or absent motor signals to the muscles activated below the level of the lesion
what are the changes in motor control in spinal cord injury and how do compensatory movements come into play?
- motor control
– motor impairments
– spasticity
– sensory impairments
– multiple systems impacted (respiratory, cardiovascular) - compensatory movements
– skills are achieved using very different motor control strategies
– use head to move hips instead of core
– rely on momentum
– muscle substitution
– task modification
what are the changes in SSPC with spinal cord injury?
- inc sway in sitting
- higher lesions demonstrate more and faster sway
- unsupported sitting was motor unstable in comparison to supported sitting posture, especially in the A-P direction
what are the changes in APC in spinal cord injury?
- compensatory strategies
– lack core muscle activation
– counterbalance to maintain COM within BOS - dec LOS
what are the changes in RPC with spinal cord injury?
- use different reactive strategies
- protective reaching vs stepping
what are the changes in information processing with spinal cord injury?
- limited somatosensory input
- must rely more heavily on vision and vestibular inputs
what are the changes in attention in spinal cord injury?
- require more attention to maintain postural control
- negatively impacts dual task ability
- potential to improve with practice
what are the changes in motor learning with spinal cord injury?
- early extrinsic feedback progressing to faded
- later intrinsic feedback to facilitate independence
- part to whole practice
- variability enhances adaptability of skills
- random practice beneficial to learning
what are the changes in memory with spinal cord injury?
- may co-exist with brain injury due to trauma, but no direct memory impairment due to SCI
what is concussion?
mild TBIs that can result in difficulties related to:
- headaches
- concentration
- memory
- balance
- coordination
what are the changes in information processing with concussion?
- sx post concussion may include
– dizziness
– noise/light sensitivity
– blurred/double vision - impaired sensory integration
- delayed speed of info processing
what are the changes in postural control and what tools can be used to measure them?
- SSPC
– acute inc sway
– related to sensory integration problems (visual, vestibular) - APC
– dec anticipatory postural adjustments prior to gait initiation - RPC
– inc latency of reactive balance responses - measurement tools
– balance error scoring system (BESS)
– sensory organization test (SOT) - instrumentation
what is the BESS?
- count # of errors in each 20 sec trial
- error:
– move hand off iliac crest
– open eyes
– step, stumble, or fall
– ABD or flex hip >30°
– lift forefoot or heel off testing surface
– remain out of test position > 5 sec - max 10 errors per condition
what are the changes in attention with concussion?
- difficulty dividing attention
- deficits persist for up to 2 months post injury
what are the changes in memory with concussion?
- working memory
– dec accuracy
– dec verbal fluency
what are the changes in motor learning with concussion?
- both recall and new task acquisition
- attempts at learning can prolong recovery
– cognitive rest
how can traumatic brain injury present?
motor, sensory, cognitive behavioral, communication
what are the changes in motor control in traumatic brain injury?
- weakness (UMN)
– spasticity - ataxia
- CN function
- ROM
- motor planning deficits
what are the changes in postural control with traumatic brain injury?
- SSPC
– inc sway
– asymmetrical WBing - APC
– high incidence of vestibular dysfunction - RPC
– studies limited
what are the changes in information processing with traumatic brain injury?
- may have reduced sensory input
- dec executive functions (prefrontal cortex)
- large dec in processing speed –> rxn time
what are the changes in attention with traumatic brain injury?
- deficits in:
– selective attention
– sustained attention
what are the changes in memory with traumatic brain injury?
- post-traumatic amnesia is common
– ranges from minutes to weeks (in rare cases months) - deficits in working memory associated with:
– frontal lobe damage
– impaired executive functions
– impaired info processing
what are the strategies for practice and feedback for traumatic brain injury?
- practice
– distributed with frequent rests to avoid mental fatigue
– blocked for initial learning progressing to random - feedback
– explicit/augmented feedback may be beneficial early due to sensory, perceptual, and cognitive impairments
– avoid overwhelming w/ feedback - evidence supports both video self-modeling and self-generation may support learning
what is multiple sclerosis?
- immune-mediated disease that causes demyelination and degeneration within the CNS
- lesions in multiple areas at multiple times
- sx can vary by lesion location and can include sensory, cognitive, and motor
what are the changes in motor control with multiple sclerosis?
- may present with any or all of the following:
– weakness/paralysis
– spasticity
– incoordination/ataxia
– loss of ROM
what are the changes in postural control with multiple sclerosis?
- reduced LOS
- slow activation of postural muscles
– slow conduction (sensory and motor)
– slow initiation of anticipatory postural adjustments
– slow RPC - difficulty under varying/reduced sensory conditions
what are the changes in information processing with multiple sclerosis?
- sensory deficits are common
- slow conduction speeds may increase response time
what are the changes in attention, memory, and motor learning in multiple sclerosis?
deficits highly dependent on lesion location
