Exam 1 content Flashcards
What’s described below (sensory disturbances or movement disorders)?
- Electrical input is carried to the CNS though afferent axons via the spinal cord
- Fibers synapse at the brainstem and cross to the contralateral (opposite) side of the brain•Brainstem receives input from specialized senses
- Nervous system has serval pain control pathways (some suppress, some facilitate pain)
- Disruption of the optic nerve can result in vision loss
Sensory Disturbances
What’s described below (sensory disturbances or movement disorders)?
- The parietal and premotor areas of the cerebral cortex identify targets in space, determining course of action
- The cortex determines strategies for movement
- The brainstem and spinal cord are responsible to execute the task
- Areas can be remapped if injury occurs as multiple pathways exist parallel to each other
Movement Disorders
What coordinated movement disorder is described below?
(Vestibulocerebellum lesions/Spinocerebellum lesions/Anterior lobe of the cerebellum lesions/Cerebellum or posterior lobes lesions)
result in inability to coordinate eye and head movement, postural sway, and delayed equilibrium response, and postural tremors
Vestibulocerebellum lesions
What coordinated movement disorder is described below?
(Vestibulocerebellum lesions/Spinocerebellum lesions/Anterior lobe of the cerebellum lesions/Cerebellum or posterior lobes lesions)
result in hypotonia, disruption of rhythmic walking, precision of voluntary movement
Spinocerebellum lesions
What coordinated movement disorder is described below?
(Vestibulocerebellum lesions/Spinocerebellum lesions/Anterior lobe of the cerebellum lesions/Cerebellum or posterior lobes lesions)
results in disorders of the gait, loss of balance,
Anterior lobe of the cerebellum lesions
What coordinated movement disorder is described below?
(Vestibulocerebellum lesions/Spinocerebellum lesions/Anterior lobe of the cerebellum lesions/Cerebellum or posterior lobes lesions)
result in loss of motor control, perceptual and cognitive tasks, trouble with movement and timing
Cerebellum or posterior lobes lesions
What coordinated movement disorder is described below?
decreased muscle tone
Can occur on the side of the lesion on bilateral of central damage
Seen primarily in proximal muscle groups, leads to uncoordinated movements
Hypotonicity
What coordinated movement disorder is described below?
generalized weakness
Sometimes seen in cerebellar lesions
Asthenia
What coordinated movement disorder is described below?
the under or over estimation of movement towards a target
What is an example of this?
Common in cerebellar disorders
Over or under shoot during movement is known as an intention tremor
Dysmetria
What coordinated movement disorder is described below?
the inability to perform rapidly alternating movements, slow without rhythm or consistency
Dysdiadochokinesia
What coordinated movement disorder is described below?
related to dysfunction of the cerebellum.
Gait becomes wide and staggering without typical arm swing
Uneven step length, feet lifted higher than usual
Loss of adaption in change in terrain
Gait Disturbances
What Deficits in Higher Brain Function is described below?
knowledge and skills accumulated over a lifetime
Crystalized intelligence
What Deficits in Higher Brain Function is described below?
ability to reason and make sense of abstract information
Fluid intelligence
What Deficits in Higher Brain Function is described below?
largest single area of the brain (1/3)
Highest level of cognitive processing, control of emotions, and behaviors
Personality, damage can change temperament and character of a person
Slow processing of information, lack of judgment, withdrawal, irritability, lack of inhibition and apathy
Frontal Lobe
What Deficits in Higher Brain Function is described below?
inability to orient the body with external space and generate an appropriate motor response Hemineglect: does to respond to stimuli or the environment on the left side of the body Loss of the inability to draw 2 and 3 dimensional objects Spatial disorientation (lost in familiar areas)
Right hemisphere syndrome
What Deficits in Higher Brain Function is described below?
often follow a lesion to the R hemisphere
Primarily affect interpersonal relationships and socialization
Disorders of emotional adjustment
What Deficits in Higher Brain Function is described below?
disturbance in articulation, disorder of speech
Speech: mechanical act of uttering words
Dysarthria
What Deficits in Higher Brain Function is described below?
the lack of the ability to produce speech, disorder of speech
Anarthria
What Deficits in Higher Brain Function is described below?
Disorder of language, a deficit in speech production or language output accompanied by a deficit in communication
Expressive aphasia
What Deficits in Higher Brain Function is described below?
inability to read, typically caused by a lesion to the L occipital lobe and the corpus callosum
Alexia
What Deficits in Higher Brain Function is described below?
Inability to write, Lesion anywhere in the cerebrum
Agraphia
What Deficits in Higher Brain Function is described below?
an acquired disorder of skilled purposeful movement that is not a result of paresis, akinesia, ataxia, sensory loss, or comprehension
Ideomotor apraxia:is a disorder traditionally characterized by deficits in properly performing tool-use pantomimes (e.g., pretending to use a hammer) and communicative gestures (e.g., waving goodbye). These deficits are typically identified with movements made to verbal command or imitation
Ideational apraxia:
is a neurological disorder which explains the loss of ability to conceptualize, plan, and execute the complex sequences of motor actions involved in the use of tools or otherwise interacting with objects in everyday life.
What Deficits in Higher Brain Function is described below?
the inability to recognize objects, lesions of the sensory cortices
Agnosia
What Consciousness: Arousal is describe below?
restlessness, agitation, or delirium
Hyperarousal
What Consciousness: Arousal is describe below?
drowsiness to stupor/coma (coma unarousable/unresponsive, stupor takes vigorous stimulation to arouse)
Hypoarousal
What Consciousness: Arousal is describe below?
damage to the cerebral cortex where the link to the brainstem is destroyed, mentation is absent even with random movements
Persistent vegetative state (PVS)
What Consciousness: Arousal is describe below?
damage to the pons with no mental deficit but an inability to move anything but the eyes
Locked in syndrome
What Consciousness: Arousal is describe below?
destruction of both upper and lower parts of the reticular formation in the brain stem
Brain death
What’s Focused attention ?
respond to different stimuli, physical and mental components, good posture or body orientation
What’s Sustained attention?
vigilance. Attend for a long time, R hemisphere
What’s activating and inhibiting responses selectively?
Selective attention
What’s Alternating attention ?
alternating between mental tasks
What’s divided attention?
do several things at once
What region of the brain is described below?
Attends to facial expressions
Humans have more facial muscles than any other species and connection to the limbic lobe reflect emotion
Self-regulation learned in this region
Orbital prefrontal region
What region of the brain is described below?
(2 lobed medial structure) receives input from sensory receptors and relays info to the frontal cortex, cingulate gyrus, amygdala, and hippocampus
High arousal and distort senses (stress), moderate arousal facilitates transmission
Thalamus
What region of the brain is described below?
Motivation, intentional drive to act
Influences both automatic and somatic systems
Limbic syndromes involve primary emotions = what are they?
Limbic system is the area that controls human behavior
What region of the brain is described below?
Damage to the limbic system can cause in increase in rage and easy progression to violence
Amygdala
Recent/working memory =
temporary storage of information that is used in managing cognitive tasks, like learning, reasoning, and comprehension.
Recent memory: hippocampus, thalamus, and basal forebrain
Declarative memory =
facts and events, and refers to those memories that can be consciously recalled (or “declared”).
Procedural Memory =
part of the long-term memory that is responsible for knowing how to do things, also known as motor skills.
stores information on how to perform certain procedures, such as walking, talking and riding a bike
What Influences movement, complex movement patterns, inhibition of flexor reflexes
Reticular formation extends through the brain stem
Autonomic Nervous System Dysfunction
Controls the unstriated tissue, the cardiac muscle, and the glandular tissue
Sympathetic pathway & Parasympathetic pathway
Integrates visceral, humoral, and environmental information to produce coordinated autonomic, neuroendocrine, and behavioral responses to external or internal stimuli
Homeostasis
Cardiovascular, respiratory, and gastrointestinal functions
Automatic motor acts: swallowing, vomiting, and coughing
Factors affecting significance of symptoms?
Size of lesion
Location of lesion
Gradual vs. sudden onset
Age of person
Individual’s pre-morbid level of activity
Define Visual perception
the process of light on the retina transformed into images that can be compared to stored memories and other sensory input and knowledge to make a decision
Visual Screen
Environment:
1) Distance acuity: Snellen chart
2) Near acuity: near acuity chart or function task – What task?
3) Ocular mobility: follow penlight
4) Near point convergence: state when two are seen (pen light or pen)
5) Stereopsis: viewer-free random dot test
6) Accommodation: isolated letters and occlude (eye patch)
7) Saccades: alternate red and green 16 inches from face
8) Visual fields: Confrontation test
Visual perception hierarchy
Oculomotor control, visual fields, and visual acuity must be intact before moving one to higher levels: Attention – Scanning – Pattern recognition – Visual memory – Visuocognition – Adaptation through vision – = Accurate visual perception
Visual Assessment: Visual cognition =
the ability to manipulate and integrate visual input with other sensory information to gain knowledge, solve problems, formulate plans, and make decisions.
Visual Assessment: Visual memory=
create and retain a picture of the object in the mind’s eye
Visual Assessment: Pattern recognition
distinguish the object from its’ surroundings.
Visual Assessment: Visual scanning =
using saccades to focus on an object of interest.
Visual Assessment: Visual attention =
automatic eye is drawn by movement/novelty and voluntary eye is draw with a purpose
Visual Assessment: Oculomotor
control enables eye movement (quick and accurate)
Visual Assessment: Visual fields
register visual scene, ensure nothing is left out
Visual Assessment: Visual acuity
ensures the visual information is accurate
Diplopia & Assessment:
Define Double Vision
and how is it resolved?
- Double Vision – occurs when eyes are not in alignment and the image falls on the fovea in one eye (caused by ocular muscle dysfunction) and on an etrafoveal location on the other eye, perceived two images
- Resolves with monocular vision (cover one eye) if neurological
Diplopia & Assessment: To compensate individuals may adopt an abnormal head posture – What can this lead to?
muscle pain,headaches, stiff neck
Assessing Diplopia & Assessment?
Assessing: convergence and ocular motor range of motion/ ocular mobility
Cover-Uncover Test used to evoke a fixational eye movement
Diplopia & Intervention:
What are the problems with this method?
Full occlusion over one eye (wear a patch)
-socially/physically not comfortable wearing a patch;
Diplopia & Intervention:
- Partial occlusion
- Optical aides
- Eye exercises
- tape placed on individual’s glasses, blurs central vision of the partially occluded eye stopping double vision or opaque tape to the nasal field of one eye (non-dominant eye is occluded
- Optical aides = prisms
- Eye exercises = convergence (multiple examples online and in text)
Hemianopsia & Screen:
- What’s the Normal visual field ?
- During what functional tasks do we use our full visual field in?
- Normal visual field 65 degrees upward, 75 degrees downward, 60 degrees inward, and 95 degrees outward when the eye is in forward gaze position
- everything task
Hemianopsia & Screen: Hemianopsia, Hemianopia, Hemiopia =
= half blind, loss of half the vision in both eyes
Hemianopsia & Screen:
Homonymous visual field impairment is common after ..?
ABI (acquired brain injury)
Hemianopsia & Screen:
40% with spontaneous recovery =?
= likely they will have to live with the deficit
Hemianopsia & Screen:
How can OTs help?
Screen: Confrontation test
Important to differentiate between hemianopsia and neglect, they can occur together and separate (usually more aware of heminaopsia, not so aware of neglect)
Hemianopsia & Intervention:
What’s Saccadic training ?
1) train people to make broader searches
2) large scale eye movements towards the blind hemifield, 3) small scale eye movements with the goal of improving reading
What are the 6 different interventions that can be used with hemianospsia clients?
1) Saccadic training = 1) train people to make broader searches, 2) large scale eye movements towards the blind hemifield, 3) small scale eye movements with the goal of improving reading
2) Reading – use a ruler to keep track of line
3) Strengthening the person’s attention to the blind hemifield, improving the ability to direct gaze movements towards the involved side
4) Exploring the involved side more efficiently
1) make quick, large saccades to enhance overshoot of the target, 2) then scan for targets among distracters in a systematic way, 3) scan during functional tasks
5) Improving saccadic exploration towards the blind hemifield
6) Prisms
What vision impairments are most commonly observed after a stroke?
-Visuospatial impairments are the most common impairment observed after stroke, high as 38%
Also Huntington disease, Parkinson disease, TBI, and MS
Visuospatial Components: Spatial Relations?
The ability to process and interpret visual information about where objects are in space, relating objects to each other and self
What are restorative interventions for Visuospatial Components: Spatial Relations?
Restorative:
-Retrieve objects by verbal request “ get the brush on top of the dresser behind the picture frame”
- Have client place items around room, then back to starting spot verbalize where all the times are located, then gather items
- Use tactile-kinesthetic guiding
- Use landmarks for location to orient self
What are adaptive interventions for Visuospatial Components: Spatial Relations?
Adaptive:
Necessary items are in a consistent space
Mark drawers, cabinets….. where key items are
Visuospatial Components: Depth Perception
The process of the visual system that interpret depth information from a viewed scene and build 3 dimensional understanding of the scene
Restorative Intervention for Visuospatial Components: Depth Perception ?
Restorative: provide tactile-kinesthetic guiding during task = feel the depth, distance, and size during functional tasks
Feel w/c and bed to set up for transfer
Adaptive Intervention for Visuospatial Components: Depth Perception ?
Adaptive:
Adapt environment = bright tape at edges
Use intact sensory systems
Tactile = when pouring place finger in cup (not hot water)
Verbal cueing especially if safety concern
Educate client and family – of what?
Visuospatial Components: Figure-Ground
The ability to perceive the foreground from the background in a visual array
Visuospatial Components: Figure-Ground Intervention (remedial approach)
TX Remedial approach: challenge the client to locate objects in similar color disorganization
Visuospatial Components: Figure-Ground Intervention (adaptive approach)
TX Adaptive approach: increase organization of items, decrease clutter and visual array, mark similar items with visual marker (tape)
What are the 3 cognitive assessments?
- Functional Cog assessments
- Domain specific Cog assessments
- Environmental Cog assessments
What’s the Functional Cog assessments
Functional Cog Assessments:
- Direct observation of functional performance.
- Perceived (sensory processing), Recall (memory), Plan (evaluate), and Perform (successful completion) system used during any task to measure performance
- Kettle Test, The Executive Function Performance Test, Kitchen Task Assessment
What’s the Domain specific Cog Assessments?
Here and now measures (static), provide a baseline, more in-depth understanding of cognitive deficits
What’s the Environmental Cog Assessments?
-Contextual factors and increase or decrease cognitive demands – How? Give an example
-The Analysis of
Cognitive Environmental Support
-Safety Assessment of Function and the Environment for Rehabilitation
What are the 5 Primary Cognitive Operations?
Self-Awareness Overview Evaluation Intervention Orientation Attention Memory Executive Functioning
Self-Awareness: Overview
- Lack of knowledge about one’s cognitive/perceptual limitations and functional implications and deficiencies in metacognitive skills
- Causes can be psychological (denial) or neurological
Define
Intellectual awareness:
Emergent awareness:
Anticipatory awareness:
- Intellectual awareness: verbally describe limitations in functioning
- Emergent awareness: recognize a problem only when it is happening
- Anticipatory awareness: anticipate that an impairment will likely cause a challenge
What are some Self-Awareness: Interventions?
Multicontext approach – The CO-OP approach – Self-Prediction - Specific Goal Rating – Videotape Feedback – Self-Evaluation – Self-Questioning – Journaling –
What’s orientation? Disorientation?
Interventions?
The ability to understand the self and the relationship of the self and the past and present environment.
-Disorientation - significant impairments in attention and memory
-Intervention:
Environmental adaptations- such as what?- external cues, posters/calendars, pictures of family, electronic reminders, arrows pointing to different places
Attention: Overview & Eval
- Detect/React
- Sustained attention
- Selective attention:
- Shifting of attention
- Mental tracking (divided attention):
-Evaluation:
- Detect/React: ability to detect and react to changes in the environment
- Sustained attention: ability to consistently engage in an activity over time
- Selective attention: Ability to attend to relevant stimuli while blocking out distracting stimuli
- Shifting of attention (alternating attention): ability to shift or alternate attention between tasks with different cognitive and motor requirements
- Mental tracking (divided attention): ability to simultaneously keep track of 2 or more stimuli during ongoing activity
- Evaluation: Test of Everyday Attention
Attention: Intervention
adaptive environment?
- To minimize attentional demands: Such as what?
- Reduce visual clutter, interruptions, auditory distractions
- Simplify to one step at a time
- Reduce number of items or choices
- Pre Select relevant items for a task
- Task segmentation (one part of task at a time)
- Visual cues for items (colored tape)
Memory: Overview Working memory: Declarative memory: Procedural memory: Prospective memory: Short term memory Long term memory -
Working memory: the temporary storage of information while one is working with it or attending to it (short term memory)
Declarative memory: one aspect of long term memory, conscious memory of events, knowledge, or facts (long term)
Procedural memory: ability to remember how to perform an activity or procedure without conscious awareness (long term)
Prospective memory: ability to remember intentions or activities that will be required for the future
Short term memory - need to have sustained attention for at least 30 sec
Long term memory - a few weeks old to first memories of childhood
Memory: Evaluation & Intervention
Evaluation: need to address the different types of memory
Intervention: attentional training, external aids/devices, errorless learning, vanishing cues, spaced retrieval
Executive Functioning: Overview
4 primary components?
Broad range of skills that allow a person to engage in independent, purposeful, and self-directed behavior
Planning, cognitive flexibility, organization, problem solving, and self-regulation
-4 primary components: Volition – Planning – Purposeful action – Self-awareness/ self monitoring –
Executive Functioning: Eval ?
Evaluation:
- Allen Cognitive Level Test
- Multiple Errands Test
- Kitchen Task Assessment (KTA)
- Routine Task Inventory (RTI)
- Executive Function
- Route-Finding Task
- Executive Function Performance Test (review for onsite)
- Management of Everyday Technology Assessment (MET)
Executive Functioning: Intervention
Intervention: -Strategy training -Verbal mediation –Problem solving strategies – Goal management training: 1) stop and define what they are doing, 2) define the main task, 3) list the steps, 4) learn the steps and do it, 5) check if I am doing what I planned
- Checklists
- Adaptations to Environment/Task
What’s Aphasia
A multiple modality language disorder, deficits in spoken, understanding writing, gestures (all forms of language)
What’s Broca’s aphasia?
What kind of stoke can cause it?
Treatment ideas?
- Expressive aphasia = speaking, writing, gesturing
- Middle cerebral artery stroke
Treatment:
-Allow for increased time and use context to anticipate content
-Use visual stimuli, key words, simply pictures to communicate (gestures and drawings may be used)
-Write down numbers and content to review
-Computer based programs work for some (think the video of Laura)
Collaborate with SLP
What’s Wernicke’s Aphasia?
Treatment ideas?
- Receptive aphasia = comprehension of speech/reading
- Fluent paraphasic speech, reduced speech comprehension, and anosognosia
- Early stages may be unaware, deny stroke, and confabulate reason for hospitalization
- Begin to understand their communication is amiss
- Comprehension of written language is impaired
Treatment:
Give pt time to process, signal change in topic, state the same idea in different words, provide visual cues
Communication books
What’s Global Aphasia?
Treatment ideas?
- Common in acute phase of large, left middle cerebral artery stroke
- All language modalities are severely impaired
- Speech may be limited: automaticisms, recurrent utterances, serial speech
- Acute rudimentary understanding of spoken language
- Acute reading to familiar nouns and verbs only, write limited to single letters or random marks
- Can be withdrawn/unaware or alert, oriented, and aware
Treatment:
Direct, short instructions paired with simple and explicit language with modeling and manual cues
Do not use too many words = overwhelming
Be aware of gestures and facial expressions made
Visual prompts for topic changing
Write down key words
Perseveration: Inability to shift from once concept to another or change to cease a behavior pattern once started (termination), inability to translate knowledge into action (initiation)
Conceptual definition:
Operational definition:
- Conceptual definition: repeated movements or acts during functional performance, prefrontal = repetition of whole actions or action components, premotor = compulsive repetition of the same movement
- Operational definition: repeats movements or acts and cannot stop them once initiated, prefrontal = moves comb to mouth after brushing teeth, premotor = continues to put on shirt with no progress
Topographical Disorientation
Assess?
intervention?
Difficulty finding direction in space
-Assess:
Observe behavior
Ask client to find a location (‘go to the bathroom’)
Direct client to follow signs (‘find office # 203’)
-Intervention:
Compensatory strategies and environmental adaptations, progressively reduce as Pt demonstrates learning
Pt follows directions using a map, slowly reduce use of map, no map
Unilateral Body Neglect
Conceptual def?
Operational def?
- Conceptual Definition: failure to report, respond, or orient to a unilateral stimulus presented to affected side, can be due to sensory processing or attention deficits, usually affects left side of body (right side brain damage)
- Operational Definition: does not dress affected side, does not pull shirt down on affected side, does not correct errors on affected side
Unilateral Spatial Neglect
Conceptual def?
Operational def?
Conceptual Definition: inattention or neglect of visual stimuli to affected side, may occur with hemianopsia (unilateral visual neglect)
Operational Definition: does not account for objects in visual field on affected side, may walk into walls/doorways/objects on affected side
Lighthouse Strategy (LHS)
Cancellation test administered during initial eval:
Scored, Pt is shown letters missed (H’s)
- “I teach a strategy to help people pay batter attention to their left (or right). See how you missed these? I can help”
- Shown image of light house, your eyes are the light beam….
-Scanning task to all fields set up
Verbal cues “ like a light house”, tactile cues (tap on left shoulder),
Image used as a cue for other therapists and in room (lighthouse
Spatial & Body Neglect Interventions
-Limb Activation
Any movement to the contralateral side will serve as a motor stimulus, activating right hemisphere and improve neglect
Find the limb and complete any small movements, engage affected side in task
-Partial Visual Occlusion
Half patch significant difference than no patch (not full patch)
-Environmental Adaptation
When lack awareness and ability to complete compensatory strategies
Family and staff can participate
-Sensory input to neglected side: grab attention via
Tactile: electrical stimulation/vibration to neck
Auditory: tapping, TV, music
Visual: bright colors; video feedback
Somatoagnosia
Conceptual def?
Operational def?
Conceptual Definition: Disorder of body scheme, diminished awareness of body structure and failure to recognize own body parts and their relationship to each other, difficulty relating own body to objects in external environment
Operational Definition: puts legs into arm holes, brushes mirror image of teeth, attempts to dress therapist’s arm
Anosagnosia
Conceptual def?
Operational def?
Conceptual definition: denial or lack of awareness of paretic extremity, lack of insight regarding paralysis, paralyzed extremity may be referred to as an object or perceived as out of proportion to the body
Operational definition: Does not identify paralyzed body part as their own, may deny as a spate object or reject it “Somebody’s arm”
Anosagnosia Assess & Treat
Assess: (Henrichon, 2017)
observation of behavior; response to inquiry re: symptoms
Ask client to engage in (B) tasks – (+) client unable to complete (despite motor capability)
“Why are you in the hospital?”
“Can you use your ______ arm?”
“Show me how you lift your leg”
-Restorative: visual feedback – video feedback – sensory input – reality checking – feedback –
-Compensatory:
fall prevention – environmental modifications
caregiver education and training – condition and management
casually ‘ignore’ confabulations
Apraxia Defined
Praxis =
Apraxia =
Results from …
Praxis = Apraxia allows a person to interact with the physical world
Apraxia = A dysfunction of purposeful movement, often unaware of their deficits
Results from any damage to the brain, most of L hemisphere, often seen with aphasia
What type of apraxia is described below? (Ideational Apraxia/Dressing Apraxia/Ideomotor Apraxia)
(AKA Conceptual Apraxia)
An inability to use real objects appropriately
Difficulty sequencing tasks in proper order, may use wrong tool for a task,
Ideational Apraxia
What type of apraxia is described below? (Ideational Apraxia/Dressing Apraxia/Ideomotor Apraxia)
Inability to carry out motor act on verbal command or imitation but able to actually use the object correctly
Ideomotor Apraxia
What type of apraxia is described below? (Ideational Apraxia/Dressing Apraxia/Ideomotor Apraxia)
Motor perception disorder. Inability to plan effective motor actions required during complex perceptual tasks of dressing
This form of apraxia is questioned as seen as an extension of ideation or ideomotor
Dressing Apraxia
Types of Apraxia:
Constructional Disorder
- The inability to organize visual information into meaningful spatial representation
- The inability to organize or assemble parts into a whole
OT Treatment: Guiding
- Place hands over patient’s whole hand down to finger tips, keep talking to a minimum, guide both side of the body when possible, move along a supported surface for tactile feedback, involve the whole body to challenge posture, provide changes to resistance, allow for mistakes and opportunities to solve problems
- Using meaningful objects and tasks will yield better results, increased repetition and practice, use natural environment and time of day if able.
- Grade number of tools and distracters, vanishing cues
- Grade steps of the activity via chaining, grade number of tasks in succession, use clear and short directions, use multiple cues for function (visual demonstration, verbal, tactile), demonstrate side by side while pt is doing task
OT Treatment: Strategy Training
- Compensatory, interventions focus on areas related to Initiation, Execution, and Control
- Initiation treated with instruction = Execution assistance =
- Control = feedback is provided when there is difficulty with control. Verbal or physical feedback used –
OT Treatment: Errorless Completion
-Person learns activity by doing it, therapist intervenes to prevent errors from occurring
Guided the hand through the task
Sitting beside the pt and doing the same action simultaneously
Demonstrating the required action and asking the patient to copy it
-Directing the pts attention to details
Key details and knowledge of the objects:
Actions connected to details are then practiced:
Specific motor actions practiced in other activities and contexts:
OT Treatment: Exploration Training
- Infer function from structure and solve mechanical problems embedded in tasks
- OT directs pt attention to functionally significant details of the objects
- Do not use the tools but explain, touch, and compare objects with photographs
OT Treatment: Direct Training
- Carry out the entire task with minimum errors (similar to errorless completion) – significant reduction of errors
- Guided movements, therapist demonstrates simultaneously
- Practice difficult parts of the task over but always complete the task
4 Components of Balance:
1) Visual
Provides information on visual orientation and flow (movement of an image on the retina, detects personal and environmental movement)
2) Somatosensory
Uses cutaneous and pressure receptors on the soles of the feet, muscles, and joints.
3) Vestibular
Determines head position and head motion in space relative to gravity
It is not ambiguous like the other two as it relies on gravity
Vestibular system is composed of the otolith & semicircular canals
4) Individual Internal Perceptions
An internal perception related to the task, themselves, and the environment
4 Components of Balance: Postural Control System
Movement Strategies
-Ankle strategy:
Maintain balance when movement is centered on the ankles
-Hip strategy:
Controls large/rapid swaying motions or when ankle strategies are ineffective
Used when center of mass approaches outer limits of the base of support
-Stepping strategy:
Used when ankle and hip are ineffective
A step is taken to widen the base of support
-Perception/Previous experience plays a role as well
Impacts sequence and degree of muscle activation
Anticipatory activities where we pre perceive may not always be accurate
3 Components of Balance: Central Nervous System
1) Cerebellum
Primary integrating and modulating force for balance
Input is modulated, interpreted, and sent out to control movements
Damage to any of these structures can result in balance/postural control deficits:
Smooth coordinated movements, timing and synergy of muscles
2) Basal Ganglia
Receives info from the cortex and cerebellum and then outputs info to the motor cortex via the thalamus
Influences automatic postural reactions (ankle, hip, stepping)
Disorders include:
3) Brainstem
Integrates vestibular input, initiates compensatory eye movements
OT Evaluation of Balance: What are the 7 Components of Assessment
Active and passive ROM Strength Vision Sensation Vestibular system Postural alignment while seated/standing Look for symmetry/ asymmetry Limits of stability
Vestibular System Defined
- Responsible for detection of forces of gravity and body motion.
- Provides information about orientation in space.
- Helps maintain clear vision (vestibular ocular reflex).
- Determines head position, direction, and speed of motion.
- Responsible for balance and postural stability
Anatomy of the Vestibular System
-Labyrinth (fluid filled – endolymph)
Detects head acceleration or a change in the rate of which the head is moving
-3 semi-circular canals
Provide sensory input about head velocity, or angular acceleration of the head
-Otolith (utricle and saccule)
Hair cells covered with a gelatinous membrane = otolith membrane
Otoconia (calcium carbonate crystals) adhere to the membrane
- Innervation
- Blood Supply
Pathology: BPPV
symptoms?
Symptoms: falling or spinning, feels uncontrollable, vertigo with head movements in a specific direction, single bouts of vertigo with times of remission, sensation lasts 20 sec on avg
Canalithiasis
the most common form of BPPV is posterior canal Canalithiasis. “Posterior” refers to the location (one can also have BPPV in the Horizontal or Anterior Canal), and Canalithiasis refers to the condition of the otoconia (
Cupulolithiasis:
occurs when otoconia adhere to the cupula and cause vertigo and nystagmus that. persist for a longer period of time.4.
Pathology: Vestibular Neuritis
(2nd most common cause of vertigo)
symptoms/assess/treatment/prognosis
- Viral infection affecting the vestibular nerve unilaterally. Onset often preceded by a viral illness such as upper respiratory infection.
- Symptoms: sudden onset of vertigo, spontaneous horizontal nystagmus, nausea, and vomiting. Spinning with eyes closed and open.
- Assess: VOR is abnormal, loss of gaze stabilization with head movement
-Treat:
Medication & Vestibular rehab
-Prognosis: slowly resolve in 6 weeks - 3 months
Pathology: Meniere Syndrome
(what are the symptoms, assess, treatment)?
Thought to be a form of endolymphatic hydrops.
-Symptoms: episodic vertigo; fluctuating, sensorineural hearing loss; sensation of fullness in the ears; and tinnitus.
Followed by rotational vertigo, postural imbalance, nystagmus, and nausea. Acute attacks. Vertigo may last 30 min to 24 hrs, symptoms abate over time with permanent hearing loss possible.
- Assess: based on symptoms
- Treat: salt restrictions, diuresis, medications, vestibular rehab, surgery in severe cases.
Pathology: Aging
Ampulla hair cell loss
Vestibular nuclei – neuronal loss = 3% per decade after age 40
Use it or lose it: the less the vestibular system is challenged, the less efficient it works.
Pathology: CNS
-What % of patients complain of vertigo with vascular causes
Stroke, vertebrobasilar migraine headache, or transient ischemic attack?
- What areas responsible for processing and interpreting vestibular &/or visual input?
- -TBI – as many as 50% have vestibular impairment, usually due to….?
-20% of patients complain of vertigo with vascular causes
Stroke, vertebrobasilar migraine headache, or transient ischemic attack
- CVA – infarct in areas responsible for processing and interpreting vestibular &/or visual input (cerebellum, basal ganglia, brainstem, occiput)
- TBI – as many as 50% have vestibular impairment, usually due to direct damage at midbrain, brainstem (damage to the vestibular and cochlear nerve)
Pathology: Peripheral onset? nausea present? tinnitus? imbalance present? hows the vision?
Abrupt onset Severe nausea Tinnitus Mild imbalance Blurred vision
Pathology:Central onset? nausea present? what kinds of symptoms ? is there hearing loss? imbalance (severe or mild?)
Gradual onset Minimal nausea \+ neurological symptoms Hearing loss rare Severe imbalance
Pathology: Unilateral both ears or one? what kind of vertigo is present? Static balance decreases or increases? nystagmus?
Only one inner ear
Episodic vertigo
Decreased static balance
Spontaneous nystagmus
Pathology: Bilateral both ears or one? over use of...(what kind of medication) what induces nystagmus? what kind of vertigo is present?
Both inner ears
Likely overuse of certain antibiotics
Head movement induces nystagmus
Constant vertigo
Rehabilitation & OT Intervention:
Goal?
- To reduce or eliminate vertigo, oscillopsia (illusory movement of the visual world), improve safety, decrease falls, and increase independence.
- Non invasive, graded simple to complex, client-centered
Substitution, Adaptation, & Habituation (Funk, 2008)
Rehabilitation & OT Intervention: Substitution
- Develop new strategies for gaze and postural control through strengthening visual and proprioceptive inputs in the absence of vestibular function
- Compensatory strategies for CNS dysfunction, or degenerative diseases/permanent damage to peripheral
Example: education if damage is permanent = change position slowly, focus on distant object while walking, sitting in front seat of car, blink eyes with head turns, use cane for support
Rehabilitation & OT Intervention: Adaptation
-Promotes postural stability by training the CNS to compensate for abnormal vestibular inputs
**Examples:
Use eyes while head and body are in motion, exercises using varying speeds of head movement, balance exercises on unstable surface with eyes open and closed
Golfing, bowling, tai chi, tennis, yoga to resolve vestibular asymmetry, improve balance, postural stability, and feelings of dizziness.
Client sits on a balance ball, reads two lists of words while moving head side to side.
Rehabilitation & OT Intervention: Habituation
- provoking symptoms too..?
- repetitive rotations of the head to elicit…?
- what kind of target is used while moving the head ?
- Provoking symptoms to increase the tolerance threshold to eventually extinguish/reduce them
- Repetitive rotations of the head to elicit vertigo and desensitize the system
- Visual target while moving the head is used (reaching overhead, bending over, looking up)
- Exercises and functional movement patterns unique to the individual that set off symptoms are prescribed (3x/day x 5 minutes). Client will initially experience an increase in symptoms for the first 1-2 weeks, and then begin to experience a lessening of symptoms.
Integrates visceral, humoral, and environmental information to produce coordinated autonomic, neuroendocrine, and behavioral responses to external or internal stimuli
ANS
_____________enter at the brainstem, motor control of head and neck.
Cranial nerves
