Exam 2 Flashcards
how to address sensory function
Observation during functional tasks
Hands-on assessment strategies
Interview questions
what are sensory functions
Vision Hearing Smell and taste Touch Pain Proprioception Vestibular Functioning
purposes of sensory evaluation
Assess extent of sensory loss
Evaluate and document sensory loss
Identify lesion location
Determine functional impairment and limitations
Provide direction of treatment interventions
Determine time to begin sensory re-education, safety education, desensitization
why is sensory assessment critical
Deficits may present safety risks to individuals who are older, have neurological impairments and live alone.
special senses
Olfaction
Vision
Gustation
Audition, balance and equilibrium
somatosensory
Primary somatosensory
Cortical (secondary somatosensory)
CN 1
Olfactory
CN 2 (vision)
Optic
Gustation CN
CN 7 Facial and CN 9 Glossopharyngeal
Audition, balance, and equilibrium CN
CN 8 Vestibulocochlear
Sensory only CN
I Olfactory, II Optic, and VIII Vestibulocochlear
Primary somatosensory
light touch, pain, temperature, proprioception, tactile localization, and vibration
Cortical (secondary) somatosensatory
2 point discrimination, stereognosis, graphesthesia (feeling), simultaneous stimuluation, and pain
detects bitter taste
CN 9 Glossopharyngeal
receptors associated with touch, pressure, stretch, vibration
mechanoreceptors
receptors associated with cell injury or damage
chemoreceptors
receptors associated with heating and cooling
thermoreceptors
where are mechanoreceptors found
skin, blood vessels, and ear
where are chemoreceptors located
tongue, blood, nose, and tissue
where are thermoreceptors located
skin and hypothalamus
receptors that detert pain
nocioreceptors
receptors that detect pain
nocioreceptors
what do free nerve endings detect
pain and temperature
what do Meissner’s corpuscles detect
light touch, vibration, and stereognosis
what do Pacinian corpuscles detect
pressure
what do Ruffini’s corpuscles detect
stretch of skin
what do hair follicle receptors sense
hair displacement
what are the fine touch cutaneous sensory receptors
meissner’s, Pacinian, and Ruffini’s corpuscles
what are the coarse touch cutaneous sensory receptors
free nerve endings, nocioreceptors, thermal receptors
Fast, sharp pain
A delta fibers
slow, hard to localize pain
C fibers
Awareness of joint position
Direct effect at SC through muscle spindles
Significant connections to cortical and cerebellar pathways with resulting impact on motor learning and adaptation
Proprioception
receives information about the type and location of sensory stimulation by conscious relay pathways
cerebral cortex
3 neuron pathway components
Discriminative touch, conscious proprioception and stereognosis
Direction of the 3 neuron pathway
Sensory receptors to medulla
Medulla to thalamus
Thalamus to cerebral cortex
there’s a heavy amount of sensory receptors in
Tongue Lips Hands Face Eyes Ears Nose
Any interruptions along ascending sensory pathway or in sensory areas of cortex may result in
decrease or loss of sensation
decrease or loss of sensation can result in
impaired tactile and proprioceptive sensation, astereognosis, increased pain, etc
Guidelines for assessment planning with cortical injury
quickly assess non-affected side, thoroughly assess affected side, if fine touch and proprioception are intact no need to assess temperature or pain, if pain and temperature are absent, no need to assess fine touch or proprioception
what is plasticity of the brain influenced by
sensory input, learning, and experience
choice of intervention depends on
diagnosis, prognosis, and evaluation results
discriminative sensory reduction interventions include
grading of objects from grossly dissimilar to more similar objects
which returns first, localization of moving touch or constant touch
localization of moving touch
graded discrimination sequencing of 3 categories
Same or different
How are they the same or different
Identification of material or object
used for hypersensitivity. Usually observed when nerve trauma, soft tissue injuries, burns, amputations. Increased use of textures, weight bearing, mirror visual feedback
desensitization
Cortical reorganization in response to repetitive stimulation. Extensive repetitive stim applied to impaired site and patient does not participate
passive sensory training
types of active sensory training
Identification of number of touches Graphesthesia tests “find your thumb” without looking Identification of shape, weight and texture Passive drawing and writing
guidelines for planning assessment
Use a test with a strong stimulus
Know key sensory points within each dermatome to utilize when assessing
Bilateral testing is necessary
If patient has a known complete lesion no need to test multiple sensory modalities
Incomplete or unknown lesions = test for multiple sensory modalities
in regards to biomechanical alignment, after CVA a pt loses ability to
posturally adjust and maintain postural alignment
how will a CVA pt posture
trunk leaning toward affected side
how to measure subluxation
Palpating the subacromial space & superior aspect of humeral head Index and middle finger Seated with UE unsupported Neutral rotation Score by finger 0, 1, 2
what should you not prescribe for subluxation due to encouraging flexor tone to kick in
slings
what can you do to help subluxation
taping
Result of trauma
Improper handling or poor positioning
Most common during “mixed tone” phase of recovery
impingement
Caused from not doing anything
Soft tissue tightness and loss of ROM
immobility
If you want to do UE strengthening with a subluxation what would you do first
start with a strengthening exercise to work on scapula unless scapula is locked down, then work on tone management
Protecting a hemiplegic shoulder
Never pull on hemiplegic arm
Avoid repositioning in wheelchair by placing your arms under their arms
Avoid using slings
Avoid arm troughs
Don’t force painful ROM
Don’t raise arm in flexion or abduction without external rotation of humerus
Do not raise arm in flexion or abduction (past 90 degrees) without scapula gliding
Never use reciprocal overhead pulleys with patients who have had a stroke
Preventing shoulder pain
Maintain/increase passive GH joint ER
Maintain scapula mobility on thorax
Avoid P/AROM beyond 90* (unless scapula is gliding toward upward rotation and ER available)
Educate patient, family, staff
Teach patients/caregivers proper management during ADLs
Educate patient on different types of pain
Provide positioning to prevent a dangling UE
Proper handling of hemiplegic shoulder
Proper bed positioning Proper positioning in wheelchair Position arm on a laptray Proper repositioning in the wheelchair Proper transfers Proper sit to stand
Scapular elevation handling
Cup hand and place over head of humerus – pressure to pectoralis medial to humeral head with heel of hand
Place other hand along medial and inferior border of scapula- use heel of hand to cradle inferior border
Bring elbows down to your side
Apply pressure through heels of hand and bring entire shoulder girdle into elevation
Bring to end range
** can do in side lying on uninvolved side or in supine
scapular protraction handling
- stand in front of client
- Gently take arm and bring into forward flexion, no more than 90 degrees
- support arm at elbow and tuck it along your side to prevent IR
- with other hand, find medial border – give pressure along medial border
- glide scapula forward into protraction
- hold for second or two
upward rotation handling
While scapula in protraction, slide one hand to elbow and hold onto epicondyles
Slide other hand to client hand (as if to shake hands)
Give slight amount of ER and gently bring arm up overhead
impaired postural control considerations
Achieve proximal stability first
Research has demonstrated UE function originates from trunk
Activity analysis to determine missing trunk control components
a motor disorder that is velocity dependent. It is the exaggeration of the stretch reflex
upper extremity spasticity
4 phenomena observed with UE spasticity
Hypertonia = “clasp knife”
Hyperactive deep tendon reflexes
Clonus
Spread of reflex responses beyond muscle stimulated
Responses to stroke rehab
Hyperactive stretch reflexes Increased resistance to passive movement Posturing of extremities Excessive cocontraction Stereotypical movement synergies Other presentations of spasticity exist
traditional eval of UE spasticity
move limb quickly and feel for resistance and grade with Ashworth scale
treatment of spasticity
Prevent pain syndromes
Guide appropriate use of available motor control
Maintain soft tissue length with ROM
Avoid using excessive effort during movement
Encourage slow and controlled movements
Teach specific functional synergies during tasks
Avoid use of repetitive compensatory movement patterns
Teach specific functional synergies during tasks
Keep spastic muscles on stretch via positioning or orthotics to prevent contracture
Teach the client or caretaker specific stretching techniques targeted at the spastic muscles
Use activities to enhance agonist/antagonist relationship
Refer for pharmacologic or surgical interventions when appropriate
secondary problems of increasing spasticity
Deformity of limbs Impaired upright function Tissue maceration of palm Pain syndromes Inability to manage basic ADLs Loss of reciprocal arm swing during gait Risk of falls
Severe pain which progresses to stiffness in shoulder, pain throughout extremity, moderate swelling of wrist/hand, vasomotor changes, atrophy
shoulder hand syndrome
New planning is not required each time a task is initiated or performed.
praxis
A person can engage and perform single-step or multi-step tasks
intact praxis
related to children where they have difficulty aquiring motor planning skills
dyspraxia
related to adults were there is a disorder of the brain and nervous system in which they have inability to carry out skilled movement in the presence of intact sensation, movement and coordination
apraxia
what are the 2 cognitive processes that are interfered with with apraxia
planning (purpose) and execution (output)
Lack or “lost” Knowledge of objects and tools in terms of the action and function they serve
Lack of Knowledge of actions independent of object/tool to perform a function they serve (without object /tool in sight)
Lack of Knowledge relevant to steps and single actions needed within sequence (can they select object to perform an action
ideational apraxia
Balance between higher and lower level cognitive processes, (attention to task, executive function skills to complete the sequence of steps)
Motor sequencing errors usually with familiar tasks (occurs as result of damage to either hemisphere)
Imitation of movements, and Movement production
Object substitution and object misuse
ideomotor apraxia
clinical observations for apraxia
Observe and judge client movement errors made while client is performing a task
Observe how the client initiates, executes and controls movements
Assess motor planning skills of both hands (R and L)
Is performance in correct place and or space for movement?
Does client notice their errors, what is their awareness?
What is their response to cueing?
functional assessment methods of apraxia
Traditionally testing of apraxia consists of gesture production or use of common object
Client is asked to pantomime a task on command (“Show me how you comb your hair”, imitate tester, or to use an object)
Important to perform tests or “rule out”
sensory function, muscle strength and dexterity before testing for praxis
Also – assess visual agnosia prior to apraxia testing
Evaluate the client’s language status
which is less severe functionally, ideomotor or ideational
ideomotor
