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
Aquatic therapy for hypertonicity:
* good because buoyancy - that upward force expressed on an object in water that creates a floating roce, creates greater degree of safety and stability for ambulatory activities, eliminates effects of gravity
* so its safer due to the decreased risk of falling
Functional activity application for hypertonicity
Quadrupated position (food for breaking up extensor tone)
Rolling - rhythmic initation
Weight bearing activities
* encourages optimal limb use and attention to limb in natural ways
Tone reducing orthotics
Patient and caregiver education
* contacture prevention
* Emphasize wieght bearing as much as possible
knowledge check: Which CNS damage area causes specifically rigidity
Basal ganglia
What is an abnormal involuntary movement?
* What part of the brain is typically responsible for them?
Dyskinesia
Typically the basal ganglia causes them
think anything like tremora, dystonia, athetosis, chorea, choreoasthetosis, ballismus, tics, myoclonus
Most common involuntary rhythmic oscillations of reciprocally innervated muscles - resting, action postural, essential
Tremor
think pronation/supination of forearm (oscillations)
Persistent contraction
Dystonia
think head getting warped in a certain position
Slow, writhing movement (not controllable, involuntary)
Athetosis
Abrupt, involuntary, variable, jerky movement
Chorea
Think huntingtons
Uncontrollable, violent, flailing
Ballismus
intense and severe - think someone trying to walk and throwing their limb
Stereotypical movement or vocalization, habit spasms, sudden, nonrhythmic
tics
Brief, sudden, rapid, asymmetrical movement
myoclonus
Interventions for uncontrollable contractions and movements
Pharmalogical implications
* botox
Surgery
* deep brain stimulation
Therapeutic techniques
* Whole body viberation
* Orthoses
* resistance training w/ wts
* Stretched and seated karate
* Functional e-stem
* Peripheral cooling of limbs
* Active assited cycling
* Bright light therapy
* Neuromuscular massage
* Functional desterity training
* Transcranial stimulation
Dystonia Intervention - she likes having people contract muscles in an isolated fashion. Working on motor control
* Sensorimotor training
* Mirror therapy or mirror box
* CIMT
* TENS
* TRanscranial magnetic stimulation (TMS)
* Biofeedback
* Orthoses
* ARM cervical spine/whole body relaxation
* KinesioTape application
Is rehab effective for chorea movements?
No.
usually anything that relaxes the pt is helpful
* medications
* general exercise, customized
* Relaxation techniques
* Hydrotherapy
* Rhythmic auditory stimulation
KNOW: adding wt to extremity with tremor - ADL impact - practice
* causes co contraction of agonist and antagonistic muscles which temporally removes that osiliation - think like a seesaw - trying to balance it in the middle
Knowledge check: which of the following dyskinesias would the pt present with uncontorllable violent flailing movements?
Ballismus
Coordination requires precise cooperation between opposing muscle groups, releated interjoint muscle groups, and interlimb muscle groups for functional activities, along with normal postural control during a volitional movement
Is ataxia muscle weakness?
No, its incoordination
* so its not a strength issue, these pts can be very strong
Result of either the lack/absence of sensory (proprioceptive) input from the periphery to the cerebellum, or higher sensory centers, or a lesion/disruption in the interaction of upper and lower motor neurons
* so basically saying the cerebellum is largely responsible for it
Patients are unable to perform smooth, skilled, adequately ranged movements
* Lack of cooperation between agonist/antagonist
* don’t perform those smooth movements
Deficits seen: dysmetria (inability to reach the target), dysdiadochokinesia (difficult with rapid alternating movement), tremors, hypermetria (over shooting)
* releated: dysarthria (speaking), titubation (rhythmic shaking, type of essential tremor), nystagmus - because of the effect of the vestibular on the cerebellum
Assessment - within outcome measures
* cerebellar ataxia - imbalance regarddless if eyes are open or closed
* Sensory ataxia
Interventions for ataxia
Pharmaological interventions - some medications exist, recent in research, medication commonly prescribed for primary pathology which may influence ataxia
* mostly targeted at whatever the underlying cause of ataxia is, not one underlying cause for ataxia so not one set medication to treat it
Primary focus for rehab: functional training to obtain central, proximal and distal postural control
Visuomotor training
Equipment - weighted vest (promote proprioceptive awareness), weighted ADL tools, cycle ergometry
* if someone is feeling understable that weighted vest will calm them down
PNF Pt exercises focused on coordination
Frenkle exercises - vision as principle source of feedback
Cawthorne-Cooksey exercises - vestibular component
stable closed chain exercises are good for these pts
When treating ataxia what is the order of obtaining new control that we strive for?
Central –> proximal –> distal
Functional intervention for ataxic / uncoordinated pts
Mat activities - good because it promotes that closed chain safe method of training
Balance training (in functional positions)
Establishing central (trunk stability) before promoting proximal (shoulder and pelvic girdle) or distal contorl (limb)
* remember you want to start w/ the trunk first because we move central –> Proximal –> distal
Considerations
* Limit resistance/tasks the patient performs against gravity requiring execessive effort
* Mental fatigue from visual and cognitive control of movement - mental fatigue is real w/ these pts (when they’re trying to get the correct movement patterns down)
* remember, at first we want to focus on trunk/proximal areas, so limit that resistance in the distal extrememities (at least at first)
Remember, you can get ataxia from stroke / MS etc… (its motor incoordination)
* because someone w/ MS could absoutely have damage to that cerebellum (which is what causes most of that ataxia)
Knowledge check: Which part of the CNS does movement planning
Motor cortex (precentral gyrus)
Weakness in neuromotor disorders
* need to figure out if its PNS or CNS
* So weakness can originate in the CNS or PNS depending on the underlying pathology
CNS - Weakness example - Stroke
Weakness is due to an underlying cause due to primary central activation deficits, transynaptic degeneration, leads to secondary changes in muscle (think atrophy)
* CNS releated
* because something hapened in the brain and signals have a hard time getting outward
* Not due to that muscle distally - its the brain having a hard time connecting to it
* however, secondary changes due happen in the muscle because that UMN is having trouble connecting to that LMN, which means the muscle isnt activating corectly
* With weakness strength deficits are greater in distal than proximal muscles - makes sense, if its already a weak signal and has to travel further its not going to work well the further out it is.
Weakness in the PNS caused by GBS
Weakness is the primary clinical manifestation that affects function - primary changes
* this is a LMN disorder, so those muscles are affected directly, not indirectly
* there are now primary changes in the muscle unlike w/ UMN weakness where the muscle changes are secondary. The muscle is directly imapcted because those LMN’s are directly impacted.
Ascending loss, distal to proximal
* meaning that theres something wrong w/ those motor tracts going back up. And most distally is once again impacted here
MS is different. However, it is a CNS issue, but impacts the PNS as well.
What happens to motor units following a stroke?
* how long does it take disuse atrophy to come following a stroke
* what happens to motor unit innervation ratios
* What muscle fiber type atrophies the most following a stroke
They’re decreased
Takes 4-6 weeks
* these would be the secondary muscle changes following a storke (because stroke is a CNS disorder / weakness)
* we jump in to decrease the impact of m atrophy
Increased motor unit innervation ratios (meaning that the existing motor units have to innervate my myofibirils because there are less of them)
Impaired firing rate regulation –> leads to decreased type 2 fibers, meaning theres a higher percentage of type 1 fibers
* so its changing the relationship of the MU’s now
* know that the literal composition of the muscle is impacted / changed
Strength training in the neuro population
How long does the program have to be to promote neural adaptation?
What intensity do you need to train at to gain neuroplasticity
Program should be 6-8 weeks to see neural adaptation
Moderate- to high intentiy training may also facilitate neural plasticity at the cortical, spinal and neuromuscular levels
Benefical to both the acute and chronic stages
Specific training varies in population
* ALS vs Stroke (remembr training w/ ALS is great) but w/ stroke it is
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
Pre cautions for aquatic therapy
Precautions
* Lack of a gag reflex
* Diabetes
* Homeostatic abnormalities
* Controlled seizures
* Breathing difficulty
* Autonomic dysreflexia
* Nasogastric tube
* Colostomy/G-tube
* Serial casting
* Hypertension
* Superficial wounds
* Fear of water
* Limited water safety skills
* Chemical hypersensitivity
Contraindications for aquatic therspy
* Open wounds
* Infections
* Fever
* Bladder incontinence
* Bowel incontinence
* Tracheostomy
* Uncontrolled BP
* Casts due to fractures
* Uncontrolled agitation
* Isolation precautions
* Continuous nasal oxygen
* IV or indwelling catheter
* Incompatibility with facility infection control proceudes
* Uncontrolled seizures
* Unstable fractures
What temperature does the water have the be below for someone w/ MS’s heat sensitivity?
Below 85
Functional activities for weakness
Task oriented functional strength training
Individualized
Knowledge check: If someone is very weak you can’t just throw them into a sit to stand, you need to start w/ those faciliation techniques and then move forward.
Knowledge check: Percaution for aquatic therapy = superficial wounds
Limited PROM - Effects of immobilization
Patients with CNS pathology may not actively move their limbs as often or as far as people w/o pathology due to
* Impaired functional mobility
* Impaired motor contorl
* Impaired strength
* Frequent use of splints/orthoses
However, ecause of this they are at risk for:
* Contracture formation
* Heterotopic ossification = excessive bone somewhere
what two things can immobilization cause
Contracture formation
Heterotopic ossification
Interventions to effects of immoblization (think those contractures / hetertropic ossification)
Surgical release - surgical lengthening (tenotomies) or “release”
Therapeutic techniques
* Stretch to shortened tissue –> needs to be slow and sustained 4x15 seconds isnt gonna cut it here
* Splinting
* Serial casting
* Joint mobiizations
* heat modalities
* Referral for surgical release
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
A brain lesion where causes trouble initiating movement
Basal ganglia
A lesion where causes issues w/ motor planning?
* think any voluntary motor control
Cerebral cortex (makes sense, think the motor contorl center in the prefrontal gyrus)
Damage where in the brain causes ataxia
cerebellum
Where is cognition in the brain?
Frontal lobe
Interventions for lack of stability
* NDT
* PNF
* Stance weight bearing exercise
* Postural EX
* Biofeedback
* E-stim
* Body-weight support treadmill training
* Adjunct therapies (taping/strapping, splinting/bracing, casting, orthotics, pressure garments)
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
Knowledge check: In which diagnosis is sensory impairment perminant?
SCI
* have to use those compensatory strategies because they arent going to regain the function they’ve lost
If cardiorespiratory health and fitness is decreased, than quality of life is decreased
Can also have pulmonary impairments –> muscular weakness (lack of respiration)
Aerobic EX primes neuroplasticity
* it gets us ready - strenghtens the chance of neurplasticity
* so do something hard w/ your pts following aerobic activity - maybe that neurplasticity will encode better
Interventions for cardiovascular/pulmonary pathologies
* Physical activity vs aerobic exercise - pop an RPE scale on these
* Promote long term enfafement in aerobic EX
* Meaningful and enjoyable to the individual pt
Knowledge check: When is the optimal time in a pt session to prime neurplasticity
* Before you do the hard activity / before motor training
