Ch. 19 Pedretti (pt. 2) -- Assessment of Motor Control

Question 1

Normal postural mechanism

Answer 1

• Automatic movements/reactions that develop early in life and provide stability & mobility
• Responsible for continuous postural adjustments to movement.
• Includes normal postural tone and control, integration of primitive reflexes, mass movement patterns, righting reactions, equilibrium reactions, protective reactions and selective movement
• Disrupted when upper motor neuron system (UMNS) is damaged.
• Can cause: abnormal tone, slow and uncoordinated movements
• Therapists must assess damage to the normal postural mechanism in clients with CNS trauma or disease

Question 2

Righting reactions

Answer 2

Directs head to an upright position in space, in normal relation to trunk. W/O reaction, would have a difficult time getting out of bed, sitting up, kneeling

Question 3

Equilibrium reactions

Answer 3

Helps sustain or keep a position, first line of defense against falling, maintains or recover balance through stimulation in the inner ear

Question 4

Protective reactions

Answer 4

• Second line of defense against falling. W/O, client may be reluctant to bear weight on affected side during bilateral activities

Question 5

Assessment of Righting, Equilibrium, Protective Reactions, and Balance

Answer 5

• May be difficult to assess due to client limitations or time constraints
• Possible to assess these reactions during transfers and ADLs
• Client shifts too far beyond midline during lower body dressing
• Maintaining balance relies on normal equilibrium and protective reactions
• Assess client’s dynamic & static balance before leaving unattended on a mat table, wheelchair or during ambulatory ADLs
• The Physical Performance Test - assesses physical function during activity, includes 9 items (7 of which assess balance). Takes 10 minutes to complete (see Fig 19-5 on pg. 475)

Question 6

Primitive reflexes

Answer 6

• Include both brainstem level reflexes and spinal level reflexes

Question 7

Brainstem level reflexes: Asymmetric Tonic Neck Reflex (ATNR)

Answer 7

1. Tested with client sitting or supine
   - Stimulus: Move client’s head 90 degrees to one side
   - Response: Fencer pose present (flexor tone of limb behind head and extensor tone of limb in front of face)
2. Client may have difficulty maintaining head in midline while moving eyes toward or past midline
3. May be unable to move arms to midline, especially while supine
4. Makes it difficult or impossible to bring object to mouth, hold an object in both hands or grasp object in front of body while looking at it

Question 8

Brainstem level reflexes: Symmetric Tonic Neck Reflex

Answer 8

1. Tested with client sitting or in quadruped
   a. Stimulus: Flex client’s head and bring chin to chest
   b. Response: UE flex and LE extend
   c. OR extend client’s head
   d. Extension of UE and flexion of LE
2. Unable to support body weight on hands and knees
3. Difficulty moving from lying to sitting
4. Difficulty transferring from bed to wheelchair and vice versa

Question 9

Brainstem level reflexes: Tonic Labyrinthine Reflex (TLR)

Answer 9

1. Tested with client supine and head in mid position
   a. This positioning IS the stimulus
   b. Response: Increase in extension tone OR extension of extremities
   c. OR test while cline is prone and head in mid position
   d. increase in flexor tone or flexion of extremities
2. Severely limited in ability to move
3. Difficulty sitting up independently from supine, to rollover or sit in a wheelchair for long periods
4. While attempting to sit up, extensor tone will dominate until client is halfway, then flexor tone takes over. Continues until fully sitting, causing head to fall forward, spine flexes and client falls forward
5. Wheelchair can cause increased extensor tone as client tries to view environment, increasing risk of slipping out of chair

Question 10

Brainstem level reflexes: Positive Supporting Reaction

Answer 10

1. Stimulus: pressure on ball of foot
   a. Response: co-contraction of knee and hip joint flexors and extensors, causing rigid extension of LE
   b. May also see internal rotation of hip, ankle plantar flexion and foot inversion
2. Difficulty standing
3. Difficulty placing heels first while walking & normal body weight transference
4. Impossible to move joints while weight bearing making getting up from chair or walking down stairs difficult
5. Balance reactions compensated by other body parts

Question 11

Spinal Level Reflexes

Answer 11

• Can occur after UMN lesion

- Reflexes rarely occur in isolation

Question 12

Spinal level reflexes: Crossed Extension Reflex

Answer 12

• Increased extensor tone in one leg while other is flexed
• Normal walking pattern may be affected. In client with hemiplegia w/this reflex, if they flex their unaffected leg to walk, a strong hypertonicity occurs in in affected leg

Question 13

Spinal level reflexes: Flexor withdrawal

Answer 13

• Stimulus: sole of foot is touched, swiped from heel to ball of foot
• Response: flexion of hip, knee, ankle
• Interferes with gait and transfers

Question 14

Spinal level reflexes: Grasp Reflex

Answer 14

Client will be unable to release an object, even when active finger extension is present

Question 15

Trunk control assessment

Answer 15

• A valid assessment for clients with a CVA
• Involves four timed tests: rolling to the weak side, rolling to unaffected side, moving from supine to sit, sitting on side of bed w/feet off floor for 30 seconds
• Must evaluate strength & control in trunk flexors, extensors, lateral flexors and rotators
• Client should sit upright on mat table with feet supported
• Do not leave client unattended until trunk control has been assessed

Question 16

Trunk flexor assessment

Answer 16

• Client sits upright and then slowly moves shoulders behind hips (eccentric), then hold end-range posture (isometric), then asked to slowly return to starting position (concentric)
• Observe for unilateral weakness, fall risk, symmetry of weight shift
• Functional testing could be observing client move from supine to sit

Question 17

Trunk extensor assessment

Answer 17

Test 1 - assesses concentric trunk extensor control, needed for LE dressing and forward reach
- Sit with spinal flexion, posterior pelvic tilt
- Move into trunk extension while also moving pelvis into neutral or slight anterior tilt
Test 2 - evaluates eccentric trunk extensor control
- Seated in upright posture
- Ask client to maintain erect spine and lean forward
- Observe unilateral weakness and note end-range control
Test 3 - trunk extensors contract concentrically
- Ask clients to move shoulder back to a seated, aligned & upright position

Question 18

Lateral flexor assessment

Answer 18

• Client sits in upright position with stationary pelvis and upper trunk laterally flexed toward mat table then returns to starting position
• Lateral flexion needed for fall prevention when reaching to side

Question 19

Trunk rotation assessment

Answer 19

• Primary muscles are obliques
• Prerequisite for UE dressing and reaching across midline
• Three movement patterns evaluated:
  1. Client sits upright with neutral, stable pelvis. Client reaches across body in direction of floor. Repeat other side.
  a. Assesses concentric control of obliques and back extensors
  2. Upper trunk remains stable, lower trunk and pelvis move forward on one side. Repeat other side
  a. Assesses trunk extension with rotation
  3. Client in supine and initiates a segmented roll, lifting shoulders from surface and moving toward opposite side.
  a. Assesses concentric contraction of obliques

Question 20

Coordination

Answer 20

• Characteristics include: smoothness, rhythm, appropriate speed, refinement to minimum number of muscle groups needed, appropriate muscle tension, postural tone and equilibrium
• Controlled by cerebellum, influenced by extrapyramidal system
• All elements of neuromuscular system must be intact
• Requires intact proprioception, body scheme, ability to judge space accurately, correct timing
• Depends on contraction of correct agonist muscle and relaxation of correct antagonist

Question 21

Incoordination

Answer 21

• Non cerebellar causes include diseases and injuries of muscles and peripheral nerves, lesions of posterior column of spinal cord, lesions in frontal or post-central cerebral cortex
• Paralysis of limbs caused by PNS lesion, prevents testing for coordination
• Includes both cerebellar disorders and extrapyramidal disorders

Question 22

Incoordination: Cerebellar Disorders

Answer 22

• Can cause incoordination that can affect any body region
• Postural difficulties i.e slouching or leaning, spinal curvature
• Common signs include ataxia, adiadochokinesis, dysmetria, dyssynergia, rebound phenomenon of holmes, nystagmus, dysarthria

Question 23

Ataxia

Answer 23

• Is the delayed initiation of movement responses, errors in range and force of movement , errors in rate and regularity of movement
• Poor coordination between agonist/antagonist muscle groups
• Jerky, poorly controlled movements
• Gait ataxia → swaggering, wide-based with little or no arm swing, uneven step length and may have tendency to fall
• Poor postural stability

Question 24

Adiadochokinesis

Answer 24

• The inability to perform rapid alternating movements (such as pronation and supination)
• Can test by how many cycles a client can perform in 10 secs
• Test unaffected side first

Question 25

Dysmetria

Answer 25

• The inability to estimate the ROM necessary to reach target of movement
• Hypermetria - limb overshooting
• Hypometria - limb undershooting

Question 26

Dyssynergia

Answer 26

• Voluntary movements broken into component parts and appear jerky
• Can also cause problems in articulation

Question 27

Rebound Phenomenon of Holmes

Answer 27

• Inability to stop a motion quickly to avoid striking something
• Example: client’s arm flexed against resistance by examiner and then the resistance is suddenly released, client’s hand will hit their face/body

Question 28

Nystagmus

Answer 28

• Involuntary movement of eyeballs up and down, back and forth or rotating direction
• Interferes with head control and fine adjustments for balance

Question 29

Dysarthria

Answer 29

Explosive or slurred speech from incoordination of speech mechanism. May also vary in pitch, seem nasally

Question 30

Extrapyramidal Disorders

Answer 30

• Characterized by hypokinesia or hyperkinesia
• Parkinson’s displays hypokinesia, cogwheel and lead pipe rigidity, decrease or loss of postural mechanisms, resting pill rolling tremor
• “Parkinson’s Plus” - group of movement disorders that have signs of parkinson’s with concomitant neurologic deficits
  a. Seen in Progressive Supranuclear Palsy, has a shorter life expectancy than Parkinson’s
• Include chorea, athetoid movements, dystonia, ballism, tremor (3 types)

Question 31

Chorea

Answer 31

• Is defined as irregular, purposeless, involuntary, coarse, quick, jerky and dysrhythmic movements
• Occur during sleep
• Seen in tardive dyskinesia and Huntington’s disease
• Patients with Huntington’s have ataxic gait as well as choreo-athetoid movements
• Choreiform movements faster than athetoid movements

Question 32

Athetoid movements

Answer 32

• Are continuous, slow, wormlike, arrhythmic movements that primarily affect distal portions of extremities
• Occur in same patterns, not present during sleep
• Adult athetosis can occur after cerebral anoxia and Wilson’s disease
• Alternating extension and flexion of arm, supination/pronation, flexion and extension of fingers
• Athetosis with chorea → Choreoathetosis

Question 33

Dystonia

Answer 33

• Is the persistent posturing of the extremities (e.g. hyperextension or hyperflexion of the wrist and fingers) often with concurrent torsion of the spine and twisting of the trunk
• Often continuous and in conjunction with spasticity
• Dystonia can be primary or secondary (with other CNS disorders)
• Segmental dystonia involves 2 or more adjacent body parts
• Generalized and focal dystonia
  a. Focal dystonia involves one limb as seen in writer’s cramp

Question 34

Ballism

Answer 34

• Rare symptom produced by abrupt contractions of axial and proximal musculature of extremity
• Cause limb to fly out suddenly
• Hemiballism → one side of body

Question 35

3 Types of Tremor

Answer 35

Intention tremor, resting tremor, essential familial tremor

Question 36

Intention Tremor

Answer 36

• Associated with cerebellar disease
• Occurs during voluntary movement
• Intensified at termination of movement
• Often seen in multiple sclerosis

Question 37

Resting Tremor

Answer 37

• Occurs at rest and subsides w/voluntary movement
• Occurs as result of damage to basal ganglia
• Seen in parkinson’s

Question 38

Essential Familial Tremor

Answer 38

• Inherited as autosomal dominant trait

- Most visible when client carries out a fine precision task