Exam, Eval, Direct interventions for msk issues, mobility and functional skills Flashcards
Exam Strategies
Assess: ROM, mm extensibility, joint alignment or ortho deformities, mm tone, strength, endurance, sensation, posture motor development, ADL, mobility sills, equipment needs, and environmental accessibility
Use standardized protocols when available
Comprehensive exam should be conducted at regular intervals throughout the life span
– can use video and photos as an adjunct to clinical exam, provide a good baseline
IMSG recommends- comprehensive, multidisciplinary assessment for all individuals with MM
Exam intervals that are recommended:
new born preop, 6m, 12m, 12m, 24m, and annually thereafter continuing through adulthood
Monitor ROM, mm extensibility, strength, endurance, coordination and functional parameters should be monitored more closely during periods of rapid growth when at risk for increased loss of function
should take pre and post intervention measurements for individuals undergoing surgery or other procedures
Patient Data Mgmt System (PDMS) standardized protocol and recording format to serially monitor individuals with MM— comprehensive interdisciplinary record of assessment and intervention, facilitates communication and coordination btwn disciplines
School needs must be assessed
- completion of School Needs Identification and Action Forms— look at required health services, physical intervention instructions, safety and fire drills, preparation for school entry, edu rights and related services, academic difficulties, accessibility, psych eval, perceptuomotor deficits, visuoperceptual deficits, self- help skills, social acceptance, social/emotional issues, , transitional services, and other needs
School Function Assessment (SFA)- measures needs and abilities during school related functional tasks for kindergarten to 6th grade
- 3 sections
1. participation in a variety of school activity settings
2. task support required (physical, cognitive/behavioral, and adaptations
3. activity performance in school-related functional activities (using materials, following rules, communicating needs)
Intervention Strategies
intervention of an impairment is indicated if it interferes with function or if the deficit can progress to a point where it may negatively affect future fxn
intervention also indicated if the efficiency, effectiveness, or safety or performance and be improved
Strength, endurance, and efficiency when performing tasks should be emphasized
WB joints must be protected for prevention of OA and pain to prolong mobility
determine most efficient means of mobility for a given environment
Goal setting- important to consider multiple impairments and expectations for functional performance– must also consider cognitive, social and behavioral issues that can occur
3 interventions for developmental delays in children with MM
- developmental programming– children encouraged by parents, teachers, and therapists with a high dose of normal development activities in at risk areas— early emphasis and practice in problem areas to minimize deficits later— implemented before problem areas or delays are identified
- implemented when delays have been identified– repeat a set of graded task in the domain of concern– improved performance through practice carries over to functional activities
- teaching compensatory skills- compensation is often implemented when the other 2 approaches have not produced sufficient results or when the child is older or more severely impaired– identify and develop strategies to help the child become as independent as possible or provide adaptive equipment to compensate for underlying problems to minimize disability in daily life
Strength
UE, neck and trunk mm should be assessed for weakness– if determine weakness need to investigate further
- Thoracic and high lumbar- palpate mm to determine which portions of mm groups are functioning
- obtain dynamometer values and grip strength should be obtained– grip strength can be used to determine progressive neuro dysfunction
Specific testing of isolated LE motions is essential to determine if individual mm are functioning
- use standardized test protocols
- detect changes in strength ASAP
- need to distinguish btwn voluntary and reflexive mvmt
MMT most common method when testing strength– used to determine volitional activity in specific mm and to determine if strength varies throughout ROM
- limited interrater reliability, mm grades must change change more than one full grade to be confident that a true change has occurred
- -** grade mmt has limited validity and reliability
- using dynamometer is much more reliable and valid— obtain 3 scores and average them
- should repeat testing in more frequent intervals if strength loss is suspected
Static strength measurements should be correlated with functional measures to observe effects of fatigue and to determine the effect of reduced strength and limited endurance on function
– individuals with neurogenic mm weakness may have more variability in force product as a result of lower threshold of fatigue and slower rate of recovery
If function is present but weakness exists in mm groups that are important for postural stability, ADL, mobility, or balance of mm forces around joints, strengthening exercises are indicated
- specific mm group depends on lesion level and functional requirements
- In general strong ue’s are important for transfers and w/c mobility, and when using AD’s to walk
- strengthening of trunk improves sitting balance and postural stability
- strengthening of key LE mm groups that are critical for amb can improve gait and minimize need for orthotics or AD
mm groups should be strengthened within functional ROM
- mm re-edu with FES and biofeedback
- E-stim beneficial in increasing strength and enhance functional performance
- strengthening programs should be implemented during periods when at risk for loss of mm strength and endurance (surgery, immob, etc) and during periods of rapid growth due to changes in function
Endurance activities important for weight control, and to enhance aerobic capacity. MM must have adequate endurance to meet challenges of community mobility
- Low impact aerobic activities minimize joint stress, avoid jumping activities
- Indication for endurance training = decreased aerobic capacity, higher energy cost of mobility, and limited endurance
Mobility
Ineffective mobility = hallmark of MM
Changes in body proportion can significantly impact mobility
Options for mobility and adaptive equipment must be evaluated throughout the life span
Many adults report that it was difficult to accept the use of w/c or other AD’s as they grew up
bed mobility, floor mobility, w/c mobility, and transfers should be assessed and compared with the requirements for independent function
- – criteria for assessing mobility parameters = endurance, efficiency, effectiveness, safety, degree of independence and accessibility
- – efficiency can be measured using time required to complete a task
- energy expenditure– HR
Box22-2
Timed Test of Patient Mobility– beneficial in assessing efficiency in mobility
Functional Task Performance W/C assessment of positioning, reaching, and driving tasks
Seated postural control measure for sitting posture and functional movements
Gait
Delays in achieving amb can be expected for all children with MM, including those with sacral lesions, those with high lesions may cease walking after a period of 3-4 years of walking
Gait analysis important to monitor motor function and to assess for signs of progressive neuro dysfunction
- patients and parents often notice changes in gait pattern and endurance before they notice a diff in increased mm weakness
- also important in determination of AD and orthotics, important to examine wear patterns
- should examine patient walking typical household and community distances to determine effects of fatigue
- if possible analyze gait with and without orthotics donned
- gait parameters assessed = arm swing, trunk position/sway, pelvic tilt and rotations, compensated or uncompensated trendelenburg, excessive hip flexion/rotation, excessive knee flexion or hyperextension, toe clearance, push off effectiveness, and foot progression angle
Observational gait analysis = technique most often used in clinical settings
can also use video analysis or foot print analysis
Box 22-2 criteria for gait effectiveness, efficiency, and safety for household and community distances
– efficiency and practicality of amb can be estimated by monitoring heart rate, normal and fast walking velocity, and max walking distance
Time distance variables provide info about gait symmetry by comparing R and L differences in step leg and stance to swing ratios
- cadence and time spent in stance vs swing provides info about stability of gait
- —ex. high cadre or imbalance in stance vs swing may indicate instability
- walking velocity and cadence provide info regarding functional practicality of gait– if velocity is too low or step rate is too high—> individual may not be able to meet environmental demands
- essential to normalize time distance variables for stature
Indications for gait training: when a child starts learning to walk, when there is potential progression to new type of orthosis or ue aid, for progression to more efficient gait pattern, when there is potential for improving gait, to improve safety and confidence with advanced walking activities, and to improve the efficiency and safety of fait, transfer, and intervention of aids
Strength of quads and iliopsosas as predictors of amb potential in children with MM
- iliopsoas found as best predictors of amb
- —grade 0-3 iliopsoas strength was associated with partial to complete reliance on w/c
- —grade 4-5 iliopsoas and quad strength we almost all community amb
- quads, ant tib, and glutes were determined to have significant importance for amb in children
- —grade 4-5 ant tib and glutes classified as community amb and did not require use of AD or orthotics
*Key mm groups for community amb, in order of importance
iliopsoas, glute met and max, ant time, and hamstring
glute med strength found to be best predictor of need for aids and orthotics
Max walking velocity was correlated with hip/knee mm extensor strength
- children with MM used twice as much energy compared to typical peers when amb
- no loss classification– decreased walking velocity and increased energy expenditure compared to peers
Equipment
wide variety of adaptive equipment often required for individuals with MM
needs vary depending on level and age
be aware of available options
education of parents and patient in regard to fit and appropriateness of adaptive equipment
Look at table 22-3/22-4 for indications of lower limb orthotics
Examine orthotics and equipment yearly
– should occur more frequently during periods of increased growth, when environmental demands change, changes in lifestyle, or change in status that may affect motor control or mobility
3 Primary Reasons for Assessing the individual with MM
- to define and individual;s current status so that appropriate program planning can occur
- to identify the potential for developing secondary impairments so that preventive can me implemented
- to monitor changes in status that could indicate progressive neurologic dysfunction
