Lecture 4: Neuro Intervention: Activity and Participation

Question 1

horizontal plane = transverse plane

Question 2

Interventions for UE function:
* Address underlying impairments - coordiantion/strength/ROM
* Positioning and postural contorl - the scap is the base of the arm, so work on this for the UE as well
* Functional reaching skills
* Functional hand skills
* Mirror therapy
* Weight-bearing and joint approximation techniques - changes the proprioceptive input to joint
* Hand over hand activities for guidance - think active assist ROM (using one hand to help the other)
* Bilatearl hand tasks
* Splinting and orthotics
* Constraint induced movement therapy

Question 3

In A the person has postered in hypertonicity - high tone
* we would use those fisting techniques
* Can turn into contractures

B are contractures that formed

Question 4

Fixed contractures = need surgery to release

Contractures sometimes are flexible
* can stretch them to a point and then you hit a fixed contracture (which is where the contracture really is)

There are effective surgeries to increase muscle length and help with these

Question 5

Patterns of movement in Horizontal plane
* Supine and rolling
* Bridging and scooting
* Quadruped and creeping
* Assessment

Question 6

Horizontal plane interventions
* Bridging
* Scooting
* Rolling
* Prone on elbows
* Quadruped

I think these are horizontal plane because you’re resisting that rotation

Also should integrate PNF patterns into what we do
* think doing quadruped and adding D2 flexion

not a right or wrong way to do this

Question 7

pt is prone on elbows, what joint is most direct approximated position

Shoulder/elbow

you are getting weight through pelvis and hips but the most direct is through the shoulder/elbow

Question 8

Tendency and position varies from infancy through childhood onto adulthood
* basically saying our functional positions change w/ age

Adulthood:
* Variations of sitting based on purpose
* Long vs short sitting vs side sitting
* Affect on BOS?

Question 9

Which of the following activities requires the most stability in short sitting?
* Tub to transfer bench in shower
* other options = passenger seat in car, dining room chair (has back support), watching TV (probs back support)

Question 10

4 phases of Sit to stand

1) Flexion momentum (first picture) - this is really hard for people because people don’t want to lean forward because they feel like they’re going to fall. People also don’t want to scoot to the edge because they’re scared
2) Momentum transfer - this is transfering wt to feet - so its flexing trunk and shifting weight to feet
3) Extension - then you get hip and knee extension
4) Stabilization - so this is kind of the hold after standing up - she likes doing some activity in the stabilization phase (maybe have them press out a ball or something, just making sure they’re actaully strong in what upright stabilization phase - need this to be functional) - you need this to be able to walk

Question 11

This is how you can progress sit to stands/make them more interesting

Question 12

What is the most important treatment parameter for sit to stands?

Answer 12

Treatment intensity

have to build this up over time

Question 13

What is knowledge of performance?

Answer 13

Knowledge of performance = specific characteristics of the pts movement
* much more valuable than generic phrases such as “Thats great” or “good job”
* Be specific about what was great
* EX: - consider saying “I liked how you rocked your body forward to help you stand up” or “did you notice how much smoother your motion was the second time around? Thats progress!”

Question 14

Should you rely on internal or external focus of attention?

Answer 14

Try and rely more on external than interal focus of attention; try to relate the movement to the external environment
* Say something more along the lines of “Bend your nose over this line” not “bend farther forward”
* Or you can cut back on words by saying”bend like this” while you demonstrate the hinging motion of the pelvis rotating forward (so you’re technically the external environment)

Question 15

Avoid creating a dual task environment by giving feedback while the pt is moving. Basically saying don’t give a pt advice while they’re doing a movement (thats 2 things at once) if they arent ready for dual taasks yet
* Let the pt complete the task first and then give feedback
* This allows the pt to allocate more attention on what you are saying or showing, and attention is important for learning

Question 16

You can also use videotapes to provide visual feedback or as an instructional tool

Question 17

Interventions to improve sitting and standing
* Functional strengthening exercises
* Standing symmetry (EX: actual mirror, can also mirror pts movement with your own movement, visual reference with vertical line of tape on wall)
* Circuit training
* OKC
* Orthotics - getting someones heel sitting properly will improve transfers like crazy. If they have some kind of tone issue that is impacting the foot its going to be much easier to get them to sit or stand if we can fix this w/ an orthotic. Often orthotics are even used for non ambulatory pts because it gets their foot in a better position for transfers.
* Equipment - standing frame
* Functional Estem

Answer 17

Hes got a functional estem unit to help him get up. But also notice the vertical blue line on the mirrior remiding him to shift over

Also notice the box is under the unaffected side, meaing the affected side is having to do more wt bearing

Question 18

which leg has more wt on it

Answer 18

right side - more approximation at the knee as well

Question 19

Might be done because the pt is lacking DF or has excessive PF
* might be unable to get heels down
* We could then try to work DF in this range

Question 20

Knowledge check: To improve wt bearing on the more affected LE, the pt could place a step under what foot?

Answer 20

Would place it under the uninvolved side to have more wt bearing through more invovled side

Question 21

remember, walking isnt just sagital, need to strengthen all those muscles that do lataeral stabilization

Question 22

Interventions Locomotor Training
* Body weight support and treadmill system straining
* Robotic assisted stepping
* Treadmill training
* Overground walking
* Dance
* Virtual reality and exergaming
* Specific exercises: strengthening, balance, task-oriented circuit training
* Motor imagery

walking happens in all environments so we need to expose our pts to differenet situations they might encounter

Question 23

Body wt support treadmill training - BWSTT
* Suspends patient over a treadmill using body weight support to partially unweight the patient
* Improves symmetry and natural walking ability
* Allows PT to manually assist patient while stepping on TM - because they arent worreid about them falling
* Facilitates automatic walking movements in intensive, task-specific environment (whole-task practice) - so you can like tap their muscles while they move
* Provides a safe environment
* Can be used with patients who require physical assist to walk
* Emphasizes high intensity repetition

Benefits:
* Stepping and loading the LE can be practiced before limbs are capable of fully supporting body wt
* Gait training can be initatied earlier within an episode of care - because they dont have to support themselves as well
* Specific elements of the gait cycle (e.i., midstance, lswing phase etc..) can be promoted within a dynamic task-specific strategy
* Owing to forced stepping movements, “learned nonuse” may be prevented by focusing attention on both involved and less involved LE’s - its forcing you to mvoe
* Oppotunity to practice walking is provided without undue fear of falling
* Dynamic balance can by enhanced by decreasing BWS and increased TM speed
* Compensatory strategies to compensate for LE impairment are reduced
* Constant speed of the TM provides rhythmic input that may reinforce a coordianted reciprocal gait pattern - if im just walking normally i can change my speed/direction - when im on the treadmil i have to be consistent to keep up w/ the treadmil - so it sets your pace for you
* Hip extension is facilitated - this is very challening for pts following stroke - they’re sitting a lot so those extensors are lengthened

Question 24

Guiding Principles for Body weight support treadmill training

Load: Maximally load the LEs for wt bearing, while minimizing weight bearing on the UEs (e.g., the BWS system sustains sufficient body weight so that the pt can stand and step with minimal or no UE support)
* remember intensity matters, so you want them to wt bear close to as much as they can

Provide: Provide sensory cues that are consistent with normal walking (i.e., manual facilitation to the extensors and flexors during stance and swing respectively)

Promote: Promotes trunk, limb, and pelvic kinematics associated w/ normal walking

Promote: Promote balance and upright control consistent with normal walking

Maximize: Maximize the recovery and use of normal movement patterns and minimze compensatory movement pattrns

NOTE: its best to do this early on before a person develops poor movement patterns following a stroke

Question 25

Body weight support treadmill Training

Carry over:
* Must carry over BWSTT to overground community - after completed, practice this –> so they have to practice walking later on to lock in those skills / keep the intensity up
* Research - BWST has not demonstrated superior effectiveness over other intervention approaches, patient population unclear - so use it if it works for you pt

Question 26

Robotic-Assisted Stepping

BWTT + robtic device that moves LE’s

Exoskeletal

Every pt wants to walk, even if the have complete SCI at c7. However, its not functional to get them to walking because theres no chance they’re going to be able to do it some day. So theres better things we could be working on

Theory is kind of to wake up those stepping pattern generators to help them walk again
* when they start to get strenght back we tell them to contorl as much of the movement as possible

Question 27

Treadmill Training

Facilitates recruitment of spinal cord and brainstem circuits - central (stepping) pattern generators –> rhythmic, reciprocal muscle activity to produce coordinated gait

Task specific training –> Skill acquisition

Stable environment for the pt

Sub-max exercise stimulus increases bioenergetic efficiency (metabolic/cardiorespiratory perspective)

Patient engagement?
* the problem is that this is boring for a pt
* you can have pt walk sideways or backwards, or you can include dual tasking w/ the pt.

obivsouly not going to use treadmill on low level pts

Question 28

can also do overground gait training
* with or without devices

Question 29

Virtutal Reality (VR) and Exergaming
* Used of video or other gaming systems allowing partial or full immersion in a computer environment to mimic real world activities
* Partial: microsoft kinetc, nintendo wii
* Full: Head-worn goggles, video projectors on all sides of room

Adds varied practice environments and task challenges

Eliminates lack of interest/pt boredom

Research: small but significant benefit over standard gait interventions

Question 30

Functional Electrical Stimulation

Can apply estem during gait

FES - more specific for function (think picking up foot when walking)

NMES - just to get muscle contraction
* Less functional

Question 31

For gait - strength/balance/circuit training

Choose internvetions that are
* Specific to the outcome
* Meaningful to the pt

Question 32

Question 33

Question 34

pt can integrate everything into a circuit

if the pt wants to return to golf, than an obstical course would be great

Question 35

Motor Imagery
* Mental Reharsal of a movement
* Activates some of the same cortical structures activated during the actual movement
* Visual (imagine visual experience) (more common) or kinesthetic (imagine sensory experence)
* During = 10-20 minutes
* Pt position: Comfortable sitting
* Therapist guides pt through detailed walking task

Question 36

High intensity Interval gait training - post stroke (but can do w/ any diagnosis)

Treatment strategy that maximizes exercise intensity by using bursts of concentrated effort, alternated with recovery periods

Current guidelines: moderate intensity continuous aerobic training

Use of Treadmill

Research points to acute/sub-acute stroke

Usually the intensity is bursts of 30-60 seconds w/ 4 mins of recovery
* dont memorize this. Its variable
* if a pts performance is decreasing than make sure the recovery is longer than the brust phase

The idea is to promot intensity which will in turn increase neuroplasticity

Question 37

what treatment focuses on motor rehersal?

Answer 37

Motor imagery

Question 38

Balance components - things that can impact balance
* Biomechanical constraints
* Limits of stability
* Anticipatory postural adjustments - moving out of someones way when you see them coming towards you
* Postural responses
* Sensory orientation
* Stability in gait

Question 39

This is showing balance startegies

Ankle = small adjustments

Hip = moderate

Stepping = large

Question 40

Balance - Functional teratment Categories:
* Static sitting
* Dynamic sitting
* Static standing
* Dynamic standing

Considerations
* quadruped
* Kneeling
* High/tall kneeling
* Not just for peds

You need postural stability for distal mobiltity

Question 41

Question 42

Dyanmic sitting
* Looking at progressive trunk control
* Functional weight shifting and reaching
* Functional weight shift and reaching - unstable surface
* Perturbations: internal (pt moving body parts or leaning - key is that the pt is doing it), external (us applying a push)
* Equipment

Question 43

Static standing phases
* shes probs not testing here

Phase 1:
* Firm surface, eyes open/closed, feet together, arms close to bdoy while moving head
* Compliant surface (foam) with eyes closed and feet 1-2 inches apart

Phase 2: - really whats changing is that the BOS of support gets smaller as phases progress
* Semi-tandem on firm surface, eyes open/closed, arms crossed
* Compliant surface, eyes closed intermittently, feet 1-2 inches apart

Phase 3:
* Semi-tandem on firm surface eyes closed (continuous)
* Semi-tandem on compliant surface eyes open/closed

She said think about it like this: Start in nice stable stance –> tandem –> single leg support
* decreasing BOS

Question 44

be thinking about adding in the dual task and unexpected pertibations

Question 45

Dyanmic standing:
* Pre gait
* Sit to stands -
* Symmetrical –> asymmetrical movements
* Change the surface
* Bending/reaching
* Perturbations: internal, extenral
* Stair climbing
* Obstacle course
* Goal to ambulate (so dynamic sets you up for walking)
* Equipment

Question 46

Knowledge check: when a light perturbation to someones shoulder they take 3 steps to recover. Is that normal?

This is a stepping strategy for a small stimulus, so no its not normal

Question 47

She said to know those gait speed #’s
* 1.4 - to cross roads
* functional 0.8-1.2

Find the actual numbers in the gait shit