Lecture 3: Neuro Intervention: Body Structure and Function Flashcards
Knowledge check: Which of the following key points of control is true for the starting points of NDT
Start proximal move distal
steat the pelvis and correct the posture before you move onto something
contractures due to immobility - think being in cast and not being able to move = leads to contracture
How do we asses for tone (not spasticity)
By passively moving someone
* not modified ashworth
Prognosis: Prediction of motor recovery poststroke with a primary symptom of hypotonia has been reported to be associated w/ a poor outcome if there is a lack of voluntary motor control of the leg within the first week and notiviable arm movements at 4 weeks
* dont memorize the #’s
* So time really does mattter
Slings can be good and bad for shoulder subluxations
* supports the arm, but tightens the streuctures in and around the arm (contractures)
contractures shouldnt happen and can be prevented
Hypotonia: treatment techniques:
Weight bearing: - getting pts up in moving quickly is important because they get that weight bearing. Obviously if theres low tone and weakness you’re going to have to be safe about your movements
* enhance, promote, and stimulate more normal postural alignment, motor control, and functional extremeity use
* joint approximation - facilitation technique as a result of weight bearing
* Goal - muscle activitation: position of UE is latearl to the body in shoulder abduction, external rotation, elbow extension, wrist extension, and finger extension.
* Goal: osteoporosis prevention and circulatory stimulation.- EX: LE weight bearing post chronic SCI
* Goal postural alignment.
* Add facilitation techniques if needed. EX: think muscle tapping - this might help them get up and weight bear
Make these dynamic as you go, to progress exercise:
* Weight-shifting, unilatearl reaching, manipulation of objects with a fixed component, limb mobement from a target, and holding and sustaining graded movements
This is an example of wt bearing. shes approximating his shoulder
Facilitation Tehcniques (for muscl activation)
Neuromuscular + Sensory stimulation techniques are combined for this
* remember its harder to target sensory but a lot of these techniques are both
Gaol: To increase muscle tone and muscular activity
Techniques include:
* Quick tapping
* Quick stretch
* Vibration
* Manual contacts
* Resistance
* Approximation
* Fast brushing/icing
Quick Stretch/Tapping - to help treat hypotonicity
Goal: Facilitate muscle contraction
HOW: Manually apply a brief quick stretch to the muscle, quickly tap, or apply vibration to the muscle belly or tendon
* So its best to tap when its already lengthened out
Most effective when the muscle is first placed in a lengthened position, placing the muscle spindle on stretch
Utilizes the stretch reflex and results in a muscle contraction
Contraction is short lived –> follow with active motion or light tracking resistance
* Think if they’re trying to flex the elbow but can only get halfway, well I’m going to grab their arm and lightly push it back up into flexion = light tracking
Manual Contacts, Apporximation and use of Resistance - for hypotonicity
Cocontraction - increases joint stability due to activation of muscles arounf the joint
Tracking resistance - don’t want to overpower the muscle
What is irradiation/overflow?
Irradiation/overflow - applying maximal resistance to a stronger muscle or muscle group may result in facilitation of a muscle contraction in weaker muscles within the same synergistic movement or in the contralatearl extremity
* EX: Resistance to the hip flexors may facilitate ankle DF’s in the same limb or resistance to ankle dorsiflexion on the right side may overflow to the left
Essentially power flows elsewhere when you’re contarcting a very strong
* resistance at hip flexors can make the Df’s go off
* YOu can use this to your advantage
Fast Brushing / Icing for muscle hypotonicity
* Activating tactile and thermoreceptors through brief quick strokes of the skin over a muscle with ice or with the fingertips may promote a muscle contraction
* Contraction is short lived –> follow with active motion or light tracking resistance
* Use with caution if patient presents with autonomic instability or who are already in a heightened state of arousal (could could be too much for someone) due to potential autonomic sympathetic response
Strengthening - treatment for hypotonicity
Goal: To improve motor unit recruitment if able to facilitate muscle activity
* obvisouly if they dont have anything this is a different story
Perform facilitation techniques then follow up with resistance to improve muscle contraction
Light tracking resistance –> maximal allowable resistance while maintaing smooth coordinated movement against gravity
* so you’re essentially helping them when they get stuck
* Don’t want movement to be wonky
Tools: manual resistance, use of gravity and body weight, and tools such as weights, theraband, etc.
Shoulder Strapping/Taping - for hypotonicity
Mechanism to reduce shoulder subluxation or prevent shoulder pain in individuals poststroke, either as a stand-alone intervention or in combination with electrical stimulation
Not much research to back this up
When taping, place GH in optimal starting position
Neuromuscular electrical stimulation (NMES) - tx for hypotonicity
Delivers electrical current to specific muscles or peripheral nerves to (in the case of hypotonia or flaccidity) facilitate active muscle contraction and prevent disuse atrophy
Can decrease shoulder subluxation
Key muscles to reduce inferior displacement of humeral head: supraspinatus and posterior deltoid
Research shows potential in initiating early poststroke to prevent subluxation (inconclusive in chronic shoulder subluxation)
Parameters: stimulation should eleicit a motor contraction in the supraspinatus and posterior deltoid at more than 30 hz gradually progressing from 1 to 6 hours per day
* do not memorize parameters
note: subluxation isnt just joint, it can even lengthen muscles
What two muscles are targets w/ NMES to reduce displacement of humeral head?
Posterior deltoid
Supraspinatus
Applying NMES to functional activities:
Functional electrical stimulation (FES) - subgroup of NMES - think using for footdrop after stroke to help that anterior tibialis work
* Applies NMES in an organnized manner to promote goal-oriented movement, which enhances functional motor learning
Functional activities
* Supine
* Sidelying
* Sitting
* Standing
* Quadruped
* Walking
Examples of interventions for hypotonicity - split in body parts
So think strenghtening the joints is the common thread / wt bearing / activating those muscles
knowledge check: which of the following is a faciliattion technique as a result of wt bearing?
Approximation
Hypertonicity: Spastic / rigid
this is UMN’s
pt has rigidity, what part of the brain is likely imapcted?
Basal ganglia
pt has hypotonia, what part of the brain is likely impacted?
Cerebellum
know that lesion ins the brainstem, subcortical white matter, and primary motor cortex lead to spastic tone - not just hypertonicity
Form of hypertonicity that is a movement disorder in which involuntary sustained or intermittent muscle contractions cause twisting and repetitive movements, abnormal postures, or both
hypertonia (dystonia)
think cervical dystonia where the neck twists
When should we treat hypertonicity?
When it interferes w/ activity
* note, if they had a SCI and got hyptonciity in legs that helps to stabilize them, well we might not treat it because its actually helping their function
What are our 4 oral medications for hypertonicity?
Orals: baclofen, diazepam, dantrolene, tianidine
What injection do we use for hypertonicity?
Botox
What does an implanted baclofen pump do?
* why is it better than oral medications for this?
Implante under skin @ lower abd, cath to SC out through CSF. Less general sedation effect than orals.
* helps treat hypertonicity
* great for SCI’s because it can be a targeted approach
* invasive risky surgery
NOTE: cannabis can be used to treat hyperetonicity (relaxes the body)
Interventions for hypertonicity:
Surgical interventions:
* Tendon lengthening (tenotomies) - common at Achille’s tendon - think high tone and walking on ankles - can fix this
* Selective dorsal rhizotomy - severs sensory nerve fibers, best candidate is peds with high tone - abnormal rootlets identified via EMG and cit
More drastic: osteotomies, arthrodesis
Deep brainstimulation
* invasive surgery
* helps w/ tone / tremor
* Helps at level of brain rather than level of extremeities
What does deep brain stimulation help w/
hypertonicity
Interventions for hypertonicity:
Sustained positioning and PROM
* Serial casting
Handling and physical inhibition
Equipment
* Think AFO
* dynamic splint
Serial casting:
Common adverse events caused by the cast include skin irritation and breakdown, pain, swelling, numbness, and nerve impingement
General containdications to the use of casting include medical instability, open wounds, skin infection, and cellulitits
Precaustion should be used in individuals w/ impaired sensation, cognitition, or communication
interventions for hypertonicity: all designed to inhibit tone
* Deep pressure
* Joint traction
* Rhythmic rotation
* Sustained stretch
* Warm/cold (gentle heat, prolonged ice)
* Raping
* Biofeedback
* Vibration and sonic pulses
* Estim - apply to intervated antagonist muscle group
* Acupuncture
Rhythmic rotation
how is estem applied when treating hypertonicity
Apply to innervated antagonist muscle group (I think it will essentailly stretch out the agonist by having the antagonist contract)
intventions for rigidity (not hypertonicity) - remember this is velocity independent (velocity doesnt matter)
- Massive stretch - helpful to some degree, you don’t want to push to their max where they’re fighting you though
- Physical activity and exercise
- Aquatic exercise in warm water
- Stretch exercise
- Trager therapy (gentle rocking motion)
- Whole body vibration
- Botox - very tageted because its a focal injection
- E-stem and magnetic pulse stimulation
for neuro population
Interventions for incoordiantion / ataxia
* Facilitation techniques
* NMES
* EMG biofeedback / NMES
* PNF
* Aqutics
* Exercise machines
* Traditional - OKC (PRes - progressive resistive exercise) (isokinetic exercise)
* Task specific - work in functional synergies, not isolation
Functional activities for weakness
Task oriented functional strength training
Individualized
Things to do for that immoblization (functional activities)
Stability: The aspect of motor control that allows a joint or body segment to be stable at a time when movement is not supposed to occur there
Other synonymous terms: neuromotor stability, stability motor control
Problem is releated to the way the brain controls movement
PT assessment - observation and within outcome measures + patient/caregiver report
These are what happens in theres instability at this area of the body
Functional Activities Applications - For pts w/ instability
Remember joint approximation doesnt have to be in the close packed position. Its just anything that loads the joint and pushes it togther
Transitioning between supine and sitting
* Consider quadruped position
Transitioning between sit and stand
Transitioning between stand and squat
Complex functional activities
Adjusting to the environment
If cardiorespiratory health and fitness is decreased, than quality of life is decreased
Can also have pulmonary impairments –> muscular weakness (lack of respiration)
