Intro to PT chapter 10 Flashcards
Parkinson Disease and Lou Gehrig disease (amyotrophic lateral scerosis) ALS
Onset ages 30-60
Cerebrovascular accident CVA
leading cause of long term disability.
Caused by a clot or a hemorage.
hemiparesis
contralateral to the side of the brain the CVA is on
paralysis or partial weakness on the side of the body
Other possible CVA symptoms
possible sensory impairments
speaking or understanding language
swallowing deficits
cognitive imparements
neglect of the involved side
clot busting
plasminogen activator (tPA)
Recovery from stroke
Most rapidly during first 3 months.
Continues at a slower pace after that.
Essential components of CVA rehabilitation program
- patient education to address stroke risk factors that may predispose an indivicual to a stroke.
- assessment and management of fall risk factors to prevent future injury.
- compensatory strategies including equipment use/
- Recovery of task related functions and resolve impairments.
Traumatic brain injury (TBI)
alteration in brain function, or other evidence of brain pathology, caused by an external force.
Clinical evidence:
* altered state of consciousness
* loss of memory before or after injury
* confusion or other mental status changes.
* Neurologic deficits such as weakness, visual abnormalities, sensory deficits, communication impairments, or loss of balance.
* Abnormal findings from imaging techniques.
Leading cause of TBI
Falls
Other common causes of TBI
blunt trauma, motor vehicle accidents, sports, and assaults.
TBI
Focal Injury
develop when head hits a stationary object.
Contusions or hematoma formation at the site of injury
TBI
Diffuse axonal injury
Rapid acceleration or decceleration forces.
Wide spread breakage of the long nerve axons in the brain.
Mild to severe
TBI
Accute care
Focused on life preservation and minimizing secondary mechanisms of injury such as increased intracranial pressure and hypoxia.
TBI Imparements
Cognitive impairments
Disordered level of consiousness, confusion, decreased memory storate and retrieval, impaired concentration, slowness of thinking, limited attention span, impairments of perception, communication, planning, writing, reading, and judgemnt.
TBI Imparements
Physical impairments
paresis or paralysis, dyscordination, balance deficits, spasticity, loss of joint flexibility, swallowing deficits, fatigue, reduced cardiopulmonary endurance, visual deficits, speach impairments, headaches
TBI Imparements
Emotional/behavioral impairments
depression, mood switngs, celf-centeredness, anxiety, lowered self-esteem, sexual dysfunction, restlessness, lack of motivation, and difficulty controling emotions
PT plan for TBI
focus on recovery of function within meaningful environmental contexts.
Reinforce the cognitive and behavioral strategies that are most appropriate to each individual
Impairment reduction and strength/endurance.
SCI Spinal Cord Injury
damage to the spinal cord or nerve roots resulting in temporary or permanent loss of sensation, strength and body function below the level of injury.
Leading cause of SCI
Motorcycle accidents. - second is falls. - next is acts of violence or sports
SCI
Tetrapelegia
all limbs affected
SCI
paraplegia
lower part of trunk and legs.
SCI
paresis
incomplete lesion in which some distal motor and sensory functions may be preserved.
SCI
Accute management
- preservation of life and prevention of further damage to neural tissue
- spinal cord decompression and spinal column stabilization.
- Medications to control inflammation
SCI
accute PT
- maintaining flexability and ROM
- strengthening unaffected muscles.
- Cardio capacity and endurance
SCI
immediatly after initial accute phase PT
- More vigourous functional training in a rehabilitation setting
- Transfer and wheelchair skills.
- Environmental adaptations/modifications
- Home evaluation
- other assistive technology
- family education
Vestibular Disorders
Dizziness - sensations may include feelings of lightheadedness, unsteadiness, or spinning (virtigo)
Vestibular Disorders
virtigo
spinning
Vestibular Disorders
semicircular canals
detect rotational movments
Vestibular Disorders
otolith organs
detect linear movements.
Vestibular Disorders
Vestibular nerve
send via CNS to vestibular nuclei, and cerebellum
Vestibular ganglion.
Vestibular Disorders
PT examination
history. Onset and timing. circumstances in which symptoms are provoked.
tests to see how well eyes can cordinate movements with one another and with movement of the head.
Vestibular Disorders
benign paroxysmal positional vertigo
(BPPV) Crystals of the otolith organs break free and fall into the semicircular canals, causing the sensation of spinning.
Vestibular Disorders
Other causes of peripheral vestibular pathology
viral infections, eighth cranial nerve seath tumors. toxicity from specific antibiotics, and fluctuations in flud pressures in the inner ear.
Central cerebellar strokes, and TBI can also lead to this.
Vestibular Disorders
PT focus
specific eye and head movement exercises
engasging the patient in a balance retraining program
BPPV - “Repositioning maneuver”
MS
Anormal immune attack of myelin sheath of nerves.
disturbences of the conduction of messages along the nerves.
diagnosed between ages 20 and 50 years
Occurs more frequently in areas farther from equator.
MS symptoms
- visual deficits
- tingling and numbness,
- weakness,
- fatigue,
- problems with balance
- disniness and vertigo
- bladder dysfunction
MS ebb and flow
exacerbations followed by remissions.
PT focus for MS
- primary disease impairments and functional limitations as well as secondary impairments that may have arisen because of reduced function and immobility.
- Equipment assesments
- Home or work modifications.
- care giver education
- fatigue management.
- Regular exercise - evidence for strength and endurance
Parkinson Disease PD
Neurodegenerative disease. - seen with advancing age.
tremor rigidity and bradykinesia
Parkinson Disease PD
Tremor
alternating contractions of opposing muscle groups
affects hands and feet most.
Mostly at rest.
Parkinson Disease PD
Rigidity
Disturbance in muscle tone.
Resistence when limbs or trunk are passively moved regardless of speed.
Parkinson Disease PD
Bradykinesia
slowness of movement. Most common feature and cause of disability.
Parkinson Disease PD
Other motor symtoms
Pustural instability occurs later in the disease
Parkinson Disease PD
non motor symptoms
apathy, anxiety, depression, sleep disorders, cognitive issues and constipation.
Parkinson Disease PD
treatments
Medications that restore neurochemical balance and deep brain stimulation
Parkinson Disease PD
disabilities
functional activities: moving from supine to sit, rising from a chair, walking, climbing stairs and reaching.
stooped posture
Parkinson Disease PD
PT treatments
specific movement and compensatory strategies.
target secondary problems such as weakness, decreased ROM and decreased aerobic capacity.
exercise and phisical therapy have a impact ont he brain of PD patients.
exercise helps with release of dopamine.
Guillain-Barre Syndrome
GBS - acquired neuromuscular condition that results from an inflammatory process affecting peripheral nerve.
Presents following viral infection.
symmetric progressive weakness, often beginning in the lower extremities.
Guillain-Barre Syndrome GBS
weakness in respiratory muscles requiring ventilator support
10 to 30% of individuals.
Guillain-Barre Syndrome GBS
Time frame of progression
rappidly over a period of 2 weeks, reaching a plateau after 4 weeks.
Guillain-Barre Syndrome GBS
treatments
plasmapheresis or immunoglobulin.
recovery over weeks or months.
Majority of individuals regain ability to walk within a year of onset.
Guillain-Barre Syndrome GBS
Pt focus
- Begins in hospital.
- functional training
- maintaining proper limb position and posture
- protecting weakend muscles
- protecting weakened muscles
- regaining sitting and standing postural control
- Strengthening exercises.
ALS - Lou Gehrig disease
Amyotrophic Lateral Sclerosis
Amyotrophic Lateral Sclerosis ALS - Lou Gehrig disease
cause and onset
Median age is 50s.
progressive neurologic disorder
degeneration of motor neurons.
Amyotrophic Lateral Sclerosis ALS - Lou Gehrig disease
symptoms/signs
weakness, atrophy, fasciculations (muscle twitches) and spasticity.
Weakness initially in limbs. - functional activities
bulbar muscles - speach swollowing and breathing
Amyotrophic Lateral Sclerosis ALS - Lou Gehrig disease
Needs
assistence with activities of daily living and use of powered mobility equipment and respiratory support.
survival time is 3 to 5 years.
Amyotrophic Lateral Sclerosis ALS - Lou Gehrig disease
medications
Riluzole (Rilutek - slow progression and extend life by about 3 months
edaravone - slow functional decline in some individuals.
Amyotrophic Lateral Sclerosis ALS - Lou Gehrig disease
role of physical therapy
- maximize functional abilities
- minimize secondary complications
- low intensity exercse program - energy conservation
- bracing and orthotic needs
- adaptive and assistive equipment.
neuromuscular examination
which movement system components remain functional and which may need to be addressed
neuromuscular examination
History
review of all medical records.
comorbid conditions
past health history
results of tests.
neuromuscular examination History tests
computed tomography CT
detects bony abnormalities in skill or spine, hemorrhages, brain atrophy and hydrocephalus
neuromuscular examination History tests
Magnetic resonance imaging MRI
provides detail of CNS tumors and pathologic lesions seen in MS
neuromuscular examination History tests
Angiography
identifies narrowing or abnormalities in blood vessels supplying the brain or spinal cord
neuromuscular examination History tests
lumbar puncture LP
assists with measuring intracranial pressure; also used to collect cerebrospinal fluid to identify pathogens or abnormal chemical/cellular content
neuromuscular examination History tests
Electroencephalography EEG
assists with diagnosis of seizures
neuromuscular examination History tests
Nerve conduction velocity test NCV
identifies peripheral nerve pathology
neuromuscular examination History tests
Electromyography EMG
identifies muscle pathology
neuromuscular examination History
Interview
hear firsthahd the sequence of events that brought the patient to therapy.
it provides insights into societal roles and functional activities that are important to the patient.
ascertain patient’s understanding of their condition and their goals.
neuromuscular examination
Systems Review
cardiovascular, pulmonary, integumentary, musculoskeletal and neuromuscular systms. affect, cognition, communication, learning style and behavioral emotional resonses.
neuromuscular examination Systems Review
patient data
- height, weight, vital signs.
- determine what body systems need further physical therapy assessment
- guide desision making regarding appropriate tests and measures
- determine whether a patient needs a referal.
neuromuscular examination
Tests and measures.
process allows clinicians to establish an initial examination baseline.
neuromuscular examination Tests and measures.
Berg balance scale
static and dynamic sitting and standing balance
neuromuscular examination Tests and measures.
Functional gait assessment
dynamic walking balance
neuromuscular examination Tests and measures.
Activities-specific balance confidence scale
self-reported balance confidence in upright tasks
neuromuscular examination Tests and measures.
10 meter walk test
walking speed
neuromuscular examination Tests and measures.
6-minute walk test
walking distance/endurance
neuromuscular examination Tests and measures.
5 times sit to stand
transfer skill and lower extremity function strength.
neuromuscular examination
Examination of Specific Impairments
testing for specific impairments
neuromuscular examination of Specific Impairments
Cognition
- Montreal Cognitive Assessment.
- impact design of therapeutic program, and the level of physical assistance or supervision.
- neuropsychologist is a valuable resource.
- asses changes in level of cognitive functioning.
neuromuscular examination of Specific Impairments
Communication
Receptive aphasia - can’t recieve or interpret written or verbal information
Expressive aphasia - impaired ability to communicate their needs in some manner.
neuromuscular examination of Specific Impairments
Range of Motion
ROM deficits can affect, limbs truck or neck.
measured using a goniometer.
neuromuscular examination of Specific Impairments
Motor control
capable of performing voluntary movement.
isolate and control specific muscle actions
assesed by ability to start stop reverse change speed change direction and regulate force
strength
involuntary movements can soometimes interfere with functional limb use
neuromuscular examination of Specific Impairments
Muscle Tone
Hypotonia -too low
Hypertonia - too high
- spasticity - velocity-dependent hypertonia
- Rgidity - another example of hypertonia
neuromuscular examination of Specific Impairments
Sensation and Perception
Sensation - ability to recieve sensory input from within and outside the body -essential for movement.
Perception - ability to integrate sensory information and interpret it in a meaningful manner
Perceptial deficit example- Unilateral spacial neglect - can’t integrate sensory information from one side of body.
Evaluation, Diagnosis, and Prognosis
Key elements of clinical decision-making
Synthesize data from all sources of information
(evaluation)
Classify the nature of the patient’s deficits (diagnosis)
Determine the patient’s potential for enhanced
movement and function, set appropriate goals, and
determine time needed to achieve them (prognosis)
neuromuscular
Principles of intervention goals:
- Enhancing function in meaningful tasks
- Adapting functional mobility strategies to changing task and environmental conditions
- empowering patients to solve their own motor problems when faced with novel situations
- Resolving Reducing and preventing impairments
- Promoting and supporting patient behaviors that address long term health and wellness.
neuromuscular
Principles of intervention - guiding:
- A consideration of whether the program will emphasize recovery versus compesnsatory strategies
- The influence of prevailing motor control theories
- A current understanding of neuroplasticity
- How motor learning concepts might shape the structure of the practice environment
- Motivational and attentional aspects of training
neuromuscular Principles of intervention
Recovery v Compensatory
- Functuional recovery - implies intervention that will be facilitate the patient’s ability to accomplish a task in a manor prior to neurologic injury
- Compensation - successfull task completion using alternative movement strategies or substitutions.
- Blended strategy - encouraging a patient to practice ambulating without an assistive device in therapy, while simultaneously having them compensate for a dynamic balance deficit by using a straight cane when walking outside of therapy.
neuromuscular Principles of intervention
Motor control
how movement is organized and coordinated.
neuromuscular Principles of intervention
Motor control early approaches
- ( PNF )- proprioceptive neuromuscular facilitation, Brunnstrom approach to hemiplegia, aad the neurodevelopmental treatment (NDT)
- Theory is no longer supported by research.
- Contribution of sensation to the movement system - still important
- multijoint extremity muscle activity and proximal control in normal movement - still important.
neuromuscular Principles of intervention
Motor control Current theories
- nervous system assumes an active role in movement control, but does not work in isolation.
- Theory now relies on a systms approach.
- Many different body systems work together.
- external forces play a role - gravity - momentum
- environment may affect task
neuromuscular Principles of intervention
Neuropalasticity
The brain and spinal cord’s ability to adapt and remodel themselves and the learn new behaviors and skills.
Learn new task more quickly if they engage their lesser involved extremity to the majority of the task.
importance of using impared body structures through priciples of task repitition and practice.
Principles that drive neuroplastic changes
Repetition
Specificity of action
Training intensity
Goal-directed movement
neuromuscular Principles of intervention
Motor learning
implies there has been a relatively permament change in ability to perform some type of skill
Importance of practice and feedback
Stages of motor learning
- Cognitive stage: learn what to do
- Associative stage: refine movement
- Autonomous stage: develop skill
PTs manipulate motor learning training variables; for
example:
- Practice variability (single or multiple tasks)
- Modification of the order of task practice
- Whole task vs. part task training
- Feedback variables
neuromuscular Principles of intervention Motor learning
blocked practice
practice of one task for a block of trials with low practice variability
neuromuscular Principles of intervention Motor learning
Random practice
practice of several different tasks in a random order
neuromuscular Principles of intervention Motor learning
Whole versus part-task training
practice of a complete continous task versus breaking down a task into its component parts and having the patient learn these first before tackling the entire task
neuromuscular Principles of intervention Motor learning feedback
Intrinsic feedback
sensory input about the movement process that the patient recieves from their own soensory organs
neuromuscular Principles of intervention Motor learning feedback
extrinsic feedback
movement information that comes from sources outside of the patient’s internal sensory systems (auditory or tactile cueing provided by the therapist)
neuromuscular Principles of intervention Motor learning feedback
Feedback schedule
frequency and timing of feedback
neuromuscular Principles of intervention Motor learning feedback
Nature of feedback
positive feedback - movement success
Negative feedback - movement errors
Wulf and Lewthwaite theory on motor learning
includes social cognitive factors including motivational and attentional influences.
PT - must support:
* autonomy or self-determination
* Expectation enhancement
* self-efficacy
* Use of an external focus of attention
Activity-based training Paradigms
Constraint induced movement therapy
(CIMT)
regaining use of more involved upper extremity by:
constraining use of the patient’s lesser involved arm while engaging the involved arm in intensive training and practice.
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locomotor training with body weight support
fouses on key limb movements in walking
Straps and harness and overhead suspension support body weight while the patient practices walkingl.
neuromuscular
Maanagement of imparements
Stretching and strengthening programs are frequently needed.
Maanagement of imparements
Neuromuscular electrical stimulation or functional electrical stimulation
adjuct treatments to facilitate motor control, timing of a muscle contraction, assist in ROM, or provide an orthotic assist to an extermity joint.
Maanagement of imparements
Assistive device and Bracing
assist with balance, safety and function
Promotion of physical Activity (neuro)
cronic nature of neuromuscular impairments can cause disuse weakness, deconditioning, and sedentary lifestyle.
Aerobic trainiing - positive impact on health outcomes, like aerobic capacity, gait endurance, and walking speed.
Patient Related Instruction
Educate patients about their disease and comorbidities.
patients and families need health-related education to help them optimize their capacity to function and to prevent future emergencies.
Causes of neuromuscular conditions
Pathology of vascular system
Trauma
Infection
Metabolic disturbances
Tumors
Degenerative disorders
