Managing Mvt Disorders and Ataxia Flashcards
3 types of tremors
- Intention
- Action
- Terminal
Intention Tremor
most common
begins as soon as you begin engaging in the activity
worsens as you get closer to the target
2 variables that affect intention tremors
- amount of precision (more precision = more tremor)
- Level or risk (hot liquid = more tremor)
* best way to work with this pt is to distract them
Action tremor
Once on the target, you remain tremulous
Terminal tremor
tremors at the end of movement
considered less severe, but just as functionally damaging
Hypotonia- what lesions do you see this with
Cerebellar/more posterior lesions
Dysdiadokinesia
inability to do rapid alternating movements; dependent on speed (faster they go, more they break down)
- foot taping, finger taping, pressing a break, brushing teeth, washing yourself, house activities, sexual activities
Dysmetria: definition and 2 types
problem with end point related to the hand and foot
- hypometric
- hypermetric
Hypometric dysmetria
undershooting the target (missing the curb because you’re infront of it)
* more functional than hypermetric; safer in terms of BOS; pts may be able to figure out how to adjust to hypometric functioning
Hypermetric dysmetria
Overshooting the target
Dyssynergia
“robotic movement”
- movement of one joint at a time to accomplish a movement
What are the 2 main issues for pt with movement disorders?
- impaired postural responses
- profound deficits in multi-joint movements as compared to single joint movements (inability to control degrees of freedom)
Cause of Impaired timing of postural responses
common with cerebellar dysfunction- results in LE/trunk responses coming in too early with limb movement
- unable to counteract destabilizing effects of arm mvt
- ataxic presentation
- unable to tandem walk
- PT implicaiton: proximal stability is KEY
PT implication of inability to control degrees of freedom
try to remove degrees of freedom one at a time to control the motion (adding supports and orthoses- soft collar, adductor pillows, wrist braces, etc)
Standard Evaluation Scales for pts with movement disorders
NOTE: all are impairment based!
- International cooperative ataxia rating scale (ICARS)
- Scale for the Assessment and Rating of Ataxia (SARA)
- Brief Ataxia Rating Scale (BARS)
International Cooperative Ataxia Rating Scale (ICARS)
developed to monitor effects of medications
- limb ataxia
- stance disorders
- postural disorders
- dysarthria
- occulomotor disorders
Scale for the Assessment and Rating of Ataxia (SARA)
Quantifies the major impairment areas (gait, stance, sitting, speech, dysmetria, tremor, RAMS)
* more comprehensive than the BARS- more # of items
Brief Ataxia Rating Scale (BARS)
Quantifies the major impairment areas (gait, speech, kinetic arm/leg function
Frequency Measures
Tapping tests
RAMS
Time Measures used in movement disorders
- Pegboard
- Phrase pronunciation
- writing/drawing
- standing
Issue with the standard impairment based measures for movement disorders versus ADL monitoring
Measurements will capture an improvement in impairments that is not necessarily correlating with improvement in activity functioning
Key Interventions for Movement Disorders
- Decrease degrees of freedom in the limbs and trunk (decrease number of joints moving simultaneously)
- Provide proximal stability (both internal and external)
- Change velocity (longer reach = slower, shorter = faster)
- Provide Adaptive Devices to stabilize and control degrees of freedom
- Utilize assistive technology
- Weights (first line of defense and the last resort)
- biofeedback (only case study report support)
- compression garments (neoprene sleeve, anecdotal evidence)
Stable Slide
AD addressive feeding, writing, putting on makeup, oral and face care
- holds arm so it is not hangin in place
- provides stabilization and locks out degrees of freedom
- very complex movement into simple elbow motion
Asta-Cath
AD for women who can’t cath themselves (could be game changer for d/c)
- hardest part = initial intention to get cath into urethra
- has a loop to hang device on your hand instead of holding in (removal of DOF)
- Use task training; practice over and over
- stabilize at the pelvis for optimal success
Liftware
Tremor dampening device for feeding (microprocessor in base of spoon that predicts tremors and keeps utensil parallel to the plate)
Evidence:
- improvement in feeding and transferring, but NOT the holding task
- 71-76% decrease in tremor with the device on
Weights as intervention
using weights for immobilization (weighted cuffs, vests, ADs, ADL devices, etc)
Initially works, but long term function is not there
NOT to be used EVER with MS- makes them worse!
Jones et. al: Effectiveness of OT and PT in MS patients with ataxia of the upper limb and trunk
Therapy used to improve dynamic postures and methods of performing functional tasks can result in improvements of functional ability
Strokoy et. al: Beneficial effects of postural intervention on prehensile action for an individual with ataxia resulting from brainstem stroke
Improvement in postural control influences upper extremity function affecting the speed and accuracy of the movement
- postural training sessions 1hr 3x/wk, 4wks
- increases in Fugl-Myer score and PASS score
Richards et. al: Response to intensive UE therapy by individuals with ataxia from strok
Intense motor practice can improve the UE motor function in pts with ataxia from stroke
Lig et. al: Intensive coordinative training improves motor performance in degenerative cerebellar disease
Intensive coordination training resulted in improvements of personally meaningful goals in everyday life (measured with the GAS)
Continuous training = crucial for stabilizing improvements
should become a standard of care
Miyai et. al: Cerebellar ataxia rehab trial in degenerative cerebellar diseases
Group that received immediate therapy showed significantly greater functional gains in ataxia, gait speed, and ADLs than the control group
Recommended Evaluation Steps/Procedures with Movement Disorders
- Interview (canadian occupational performance measure)
- Observe (impact of limb and trunk ataxia)
- Change task parameters; what dampens or exacerbates ataxia?
- Retrain task performance integrating techniques, movements, equipment, and positions that dampened ataxia and enhanced function
- Re-evaluate and Re-interview
Methods to change task parameters to dampen ataxia
- Control the degrees of freedom
- manual stabilization of head, upper trunk, and pelvis (soft collar)
- WB through hand or forearm
- UEs stabilized against trunk (elbows in)
- emotionally stable (if upset, worse)
- decrease reaching into space
- increase postural security (insecurities = increased titurbation)
- Decrease cognitive effort
- increase target size
- adjust velocity of movement
- add weights (last resort)
Methods of using the environment for stability
- High back chairs
- forearm WB
- stabilize head on wall
- sit at table against wall
- use corner of wall
- pillow and foam
- stabilize with one arm holding chair
Methods of retraining movements
- maintain arm contact with surface or body (slide dont reach)
- move in flexion and adduction
- co-contract trunk
- push head into back of chair
- break down movement pattern to change target (scoop, near your mouth, in your mouth)
- slow v quick movements
- slide objects/tool on counter (avoid reach in space)
TherEx useful in diminishing ataxia/movement disorder symptoms
- close chain strengthening
- proximal stability (core/scapula)
- body weight as resistance
- postural alignment
- bridges, POE, quadruped, wall squats, kneeling, w/c pushup
