Motor Control Impairments

Question 1

What occurs when tone has a neural versus non neural cause?

Answer 1

Neural: alpha motor neurons more sensitive to input

Non neural: stiffness due to immobilization/atrophy

Question 2

What is a diagnostic indicator of UMN problem?

Answer 2

stretch sensitive hyper tonicity

Question 3

How do we examine tone?

Answer 3

Passive movement of limbs at varying speeds: min, mod, severe tone or modified ashworth scale or tardieu
Is there really clinical importance to examining tone? possibly no because it may not really help patients identified problems

Question 4

What is modified ashworth scale?

Answer 4

0 no increase in tone
1 slight increase, catch at end of ROM
1+ slight increase, catch followed by minimal resistance throughout less than half of ROM
2 marked increase, part easily moved
3 considerable increase, passive movement difficult
4 affected part rigid in flexion or extension
9 unable to test

Question 5

What is treatment for hypertonicity?

Answer 5

Pharmacological: baclofen, valium, botox
Surgical: nerve block or cut
PT: slow, sustained stretching (short term effect)

Question 6

What can be done to address non neural causes of tone?

Answer 6

positioning, weight bearing, splints, casts

Question 7

What is reflex inhibiting?

Answer 7

Put someone in stretch and then make them work while they hold the stretch.
Activate GTO’s autogenic inhibition.
Temporary but allows for practice

Question 8

What are systems involved in CNS pathology Passive ROM?

Answer 8

Neural factors: reflex stiffness
Non-neural factors: effect of immobilization, limb inertia Newton’s first law, heterotopic ossification, effect of aging, pain, arthritis, scoliosis

Question 9

What are interventions for decrease in passive ROM?

Answer 9

stretching, splinting, serial casting, joint mobilization, heat modalities, surgical release

Question 10

What is research for stretching as an intervention to improve passive ROM?

Answer 10

In health people: 30 sec holds over 15 min effective at increasing ROM
Recent stroke: daily positioning for 30 min effective to prevent contracture, not effective in reducing contracture

Question 11

What is research on splinting in treating passive ROM?

Answer 11

Static hand splints: no benefit in preventing contracture following stroke, decreases function, increases pain
Dynamic hand orthosis: case reports promising
Other dynamic splints: research is variable

Question 12

What are advantages and disadvantages of serial casting in treating PROM?

Answer 12

Effective at improving ROM in people with CP and TBI.

Disadvantages: higher risk of adverse events, difficult technique/skill requirements, impaired function during casting

Question 13

What is research on joint mobs as treatment for PROM?

Answer 13

Increases PROM but no functional change with use of ankle joint mobilization in people with stroke.

Question 14

Research on heat modalities for PROM?

Answer 14

Ultrasound effective at increasing ROM in healthy subjects.
Limited research on hot packs- increased ROM in wrist in stroke
Precaution with sensory/communication/cognition deficits

Question 15

What is usefulness of surgical release when treating PROM?

Answer 15

Tendon lengthening used in kids with CP (Achilles or hamstring)
Achilles tendon lengthening in people with diabetic neuropathy to prevent pressure ulcers
Resection of HO

Recurrence rates common
Need to examine function carefully

Question 16

What are Brunnstrom stages of synergy?

Answer 16

1: no movement
2: involuntary only
3: abnormal synergy only
4: isolate one joint
5: isolate 2 joints
6: isolate all joints
7: normal movement

Question 17

What is treatment for synergy/activation problems?

Answer 17

Task specific: modify task to make it easier or harder, modify target constraints
Practice with varied timing or force demands
LE: standing, transfers, gait
UE: manipulation and dexterity (finger tapping, pick up various objects, drawing/writing, turn pages use phone/keyboard)

Question 18

What are peripheral and central factors for muscle strength and power?

Answer 18

Peripheral: length tension properties, viscoelasticity
Central: motor units, firing rate, sequencing, postural stabilization

Question 19

What happens to muscle performance with CNS pathology?

Answer 19

Decreased force production: inadequate input to alpha mn (hemi, para, tetra- plegia)
Secondary factors: incoordination, spasticity/synergy patterns, sensory loss, atrophy loss, endurance/fatigue
Muscle spindle performance: alpha gamma co-activation

Question 20

What are examination techniques for muscle weakness?

Answer 20

Valid concept? (consider synergy and standard MMT positions)
CVA: hemiplegia (strong vs. weak side)
Options: AROM/MMT, hand held dynamometer, isokinetic dynamometer

Question 21

What is treatment for muscle weakness?

Answer 21

If able to move against gravity: progressive resistive exercise for power/strength training, task specific training
Deconditioning: weakness as a secondary impairment

Question 22

What is treatment for weakness if someone has no active movement?

Answer 22

0 or 1 on MMT scale: insufficient alpha motor neuron input
Facilitation techniques: utilize stretch reflex pathway for autogenic facilitation, tapping, vibration, quick stretch, activating only alpha mn
Task specific training: modify task/environment, trying to activate alpha and gamma mn via voluntary movement pathways

Question 23

What is treatment for 2 or 3 MMT grades?

Answer 23

Person lacks anti-gravity muscle power, possibly only activating alpha mn
Use gravity eliminated positions: begin PREs
Task specific training: modify task/environment

Question 24

What is task specific training for a weak patient?

Answer 24

Modify task/environment= easier
Skill acquisition strategies: immediate feedback; manual guidance (learning + safety); blocked practice, little variation; motivation important

Question 25

What is goal for task specific training in weak patients?

Answer 25

Maximize patient initiated activity to promote motor recovery/plasticity

Question 26

How can we progress task specific training?

Answer 26

Progression: make task harder
Repetition without repetition as an exercise
Strength training: overload principle, %1 RM, low repetition, rests

Question 27

What are exam techniques for possible coordination CNS pathologies?

Answer 27

Finger to nose, knee to ankle, rapid alternating movements, nine hole peg test (only if there is active movement)
Speed and accuracy component

Question 28

What is coordination and how is it accomplished?

Answer 28

Ability to carry out any motor task precisely and quickly: motor system interacts with changing environment, sensory cortex, motor cortex, visual system, cerebellum

Multiple joints and muscles activated together at appropriate time to work together: normal movement trajectory, smooth bell shaped velocity profile

Question 29

What is intervention for coordination CNS pathology?

Answer 29

Task specific training: modify task, modify target constraints, modify timing or force demands
UE: manipulation and dexterity
LE: gait
Use of weights
Role of strength
PNF patterns
Frenkels exercise: reciprocal movements of hands/feet, trace shapes and numbers

Question 30

What are parts of the exam for unilateral neglect?

Answer 30

Observation: avoids crossing midline, difficulty with self care, ADLs
OT role

Question 31

What is treatment for unilateral neglect?

Answer 31

Task specific training: modify task/environment
Video/mirror/prism/eye patch
Encourage movement, cross midline
Minimize verbal feedback
Mental imagery practice, “lighthouse”
Adaptive: slow pace, put important items on strong side, use marker for visual scanning

Question 32

What are other perceptual CNS disorders?

Answer 32

Pusher syndrome: lean towards weak side
Apraxia: motor planning disorder
Alien hand syndrome: grasping behavior without conscious awareness of patient
Locked in syndrome: unable to communicate or move but cognitively intact

Question 33

What is the Fugl Meyer?

Answer 33

Test of motor control

Question 34

What is STREAM?

Answer 34

Stroke Rehab Assessment of Movement
Looks at strength, tone, synergy, etc to get a score
UE, LE, and functional movements
There is a shorter form: S-STREAM

Question 35

What are advantages and disadvantages of PNF?

Answer 35

Advantages: readily modifiable to allow facilitation or resistance, fits with guideline for strength training
Disadvantages: complex, indirect functional relevance

Question 36

What are PNF trunk strengthening?

Answer 36

Alternating isometrics: hold position with isometric resistance or agonists followed by antagonists
Rhythmic stabilization: modification of AI with isometric resistance provided in rotation motion
Functional positions: sidelying, sitting, standing

Question 37

What is NDT?

Answer 37

Neurodevelopmental treatment
There are requirements for normal movement: normalize tone, automatic reactions, isolated movement
Better for pediatrics, not so much for adults because the positions aren’t functional

Question 38

What are advantages and disadvantages of NDT?

Answer 38

Advantages: readily modifiable to allow facilitation, useful if manual guidance needed
Disadvantages: complex, strength not assessed, limited functional relevance

Question 39

What are advantages and disadvantages of task specific training?

Answer 39

Advantages: readily modifiable to increase or decrease difficulty, based on contemporary models–> function
Disadvantages: cognitive impairments, unable to do task

Question 40

What is evidence for task specific training?

Answer 40

Constraint induced movement therapy for UE recovery
Body weight supported treadmill training
Functional electric stimulation/FES orthotics