Managing Mvt Disorders and Ataxia

Question 1

3 types of tremors

Answer 1

1. Intention
2. Action
3. Terminal

Question 2

Intention Tremor

Answer 2

most common
begins as soon as you begin engaging in the activity
worsens as you get closer to the target

Question 3

2 variables that affect intention tremors

Answer 3

1. amount of precision (more precision = more tremor)
2. Level or risk (hot liquid = more tremor)
   * best way to work with this pt is to distract them

Question 4

Action tremor

Answer 4

Once on the target, you remain tremulous

Question 5

Terminal tremor

Answer 5

tremors at the end of movement

considered less severe, but just as functionally damaging

Question 6

Hypotonia- what lesions do you see this with

Answer 6

Cerebellar/more posterior lesions

Question 7

Dysdiadokinesia

Answer 7

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

Question 8

Dysmetria: definition and 2 types

Answer 8

problem with end point related to the hand and foot

1. hypometric
2. hypermetric

Question 9

Hypometric dysmetria

Answer 9

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

Question 10

Hypermetric dysmetria

Answer 10

Overshooting the target

Question 11

Dyssynergia

Answer 11

“robotic movement”

- movement of one joint at a time to accomplish a movement

Question 12

What are the 2 main issues for pt with movement disorders?

Answer 12

1. impaired postural responses
2. profound deficits in multi-joint movements as compared to single joint movements (inability to control degrees of freedom)

Question 13

Cause of Impaired timing of postural responses

Answer 13

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

Question 14

PT implication of inability to control degrees of freedom

Answer 14

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)

Question 15

Standard Evaluation Scales for pts with movement disorders

NOTE: all are impairment based!

Answer 15

1. International cooperative ataxia rating scale (ICARS)
2. Scale for the Assessment and Rating of Ataxia (SARA)
3. Brief Ataxia Rating Scale (BARS)

Question 16

International Cooperative Ataxia Rating Scale (ICARS)

Answer 16

developed to monitor effects of medications

• limb ataxia
• stance disorders
• postural disorders
• dysarthria
• occulomotor disorders

Question 17

Scale for the Assessment and Rating of Ataxia (SARA)

Answer 17

Quantifies the major impairment areas (gait, stance, sitting, speech, dysmetria, tremor, RAMS)
* more comprehensive than the BARS- more # of items

Question 18

Brief Ataxia Rating Scale (BARS)

Answer 18

Quantifies the major impairment areas (gait, speech, kinetic arm/leg function

Question 19

Frequency Measures

Answer 19

Tapping tests

RAMS

Question 20

Time Measures used in movement disorders

Answer 20

1. Pegboard
2. Phrase pronunciation
3. writing/drawing
4. standing

Question 21

Issue with the standard impairment based measures for movement disorders versus ADL monitoring

Answer 21

Measurements will capture an improvement in impairments that is not necessarily correlating with improvement in activity functioning

Question 22

Key Interventions for Movement Disorders

Answer 22

1. Decrease degrees of freedom in the limbs and trunk (decrease number of joints moving simultaneously)
2. Provide proximal stability (both internal and external)
3. Change velocity (longer reach = slower, shorter = faster)
4. Provide Adaptive Devices to stabilize and control degrees of freedom
5. Utilize assistive technology
6. Weights (first line of defense and the last resort)
7. biofeedback (only case study report support)
8. compression garments (neoprene sleeve, anecdotal evidence)

Question 23

Stable Slide

Answer 23

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

Question 24

Asta-Cath

Answer 24

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

Question 25

Liftware

Answer 25

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

Question 26

Weights as intervention

Answer 26

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!

Question 27

Jones et. al: Effectiveness of OT and PT in MS patients with ataxia of the upper limb and trunk

Answer 27

Therapy used to improve dynamic postures and methods of performing functional tasks can result in improvements of functional ability

Question 28

Strokoy et. al: Beneficial effects of postural intervention on prehensile action for an individual with ataxia resulting from brainstem stroke

Answer 28

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

Question 29

Richards et. al: Response to intensive UE therapy by individuals with ataxia from strok

Answer 29

Intense motor practice can improve the UE motor function in pts with ataxia from stroke

Question 30

Lig et. al: Intensive coordinative training improves motor performance in degenerative cerebellar disease

Answer 30

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

Question 31

Miyai et. al: Cerebellar ataxia rehab trial in degenerative cerebellar diseases

Answer 31

Group that received immediate therapy showed significantly greater functional gains in ataxia, gait speed, and ADLs than the control group

Question 32

Recommended Evaluation Steps/Procedures with Movement Disorders

Answer 32

1. Interview (canadian occupational performance measure) 2. Observe (impact of limb and trunk ataxia) 3. Change task parameters; what dampens or exacerbates ataxia? 4. Retrain task performance integrating techniques, movements, equipment, and positions that dampened ataxia and enhanced function 5. Re-evaluate and Re-interview

Question 33

Methods to change task parameters to dampen ataxia

Answer 33

1. Control the degrees of freedom 2. manual stabilization of head, upper trunk, and pelvis (soft collar) 3. WB through hand or forearm 4. UEs stabilized against trunk (elbows in) 5. emotionally stable (if upset, worse) 6. decrease reaching into space 7. increase postural security (insecurities = increased titurbation) 8. Decrease cognitive effort 9. increase target size 10. adjust velocity of movement 11. add weights (last resort)

Question 34

Methods of using the environment for stability

Answer 34

1. High back chairs 2. forearm WB 3. stabilize head on wall 4. sit at table against wall 5. use corner of wall 6. pillow and foam 7. stabilize with one arm holding chair

Question 35

Methods of retraining movements

Answer 35

1. maintain arm contact with surface or body (slide dont reach) 2. move in flexion and adduction 3. co-contract trunk 4. push head into back of chair 5. break down movement pattern to change target (scoop, near your mouth, in your mouth) 6. slow v quick movements 7. slide objects/tool on counter (avoid reach in space)

Question 36

TherEx useful in diminishing ataxia/movement disorder symptoms

Answer 36

1. close chain strengthening 2. proximal stability (core/scapula) 3. body weight as resistance 4. postural alignment 5. bridges, POE, quadruped, wall squats, kneeling, w/c pushup