Neuro Placement Flashcards
Sit to Stand:
Inappropriate Foot Placement
Hypothesis
ROM:
-Lack of passive ROM in knee flexion
-Lack of passive ROM in DF-Lack of concentric knee flexor activation in sitting
Strength/Weakness:
-Lack of concentric and eccentric hip flexor activation in sitting
-Lack of concentric and isometric ankle dorsiflexion in sitting
Proprioception/Sensation:
-Lack of proprioception and tactile sensation of the affected leg
Sequencing/patterning:
-Lack of coordination to activate the above muscles to place the foot in sitting
OTHER:
-Inattention/neglect
Testing Strategies for STS Inappropriate Foot Placement
ROM:
-Test Knee flexion and ankle DF passively OR in a corner with knee bends
Strength/Weakness:
- Knee concentric activation if they can actively flex the knee in sitting to place foot behind the knee. If not, can they do it with slide sheets/reduced friction?
-Hip concentric and isometric activation if they can actively flex hip and hold it in sitting to lift foot slightly. If not, in side-lying? Or in a corner with hip hinge then extend
-Concentric and Isometric DF in sitting if they can actively DF ankle and hold it in sitting.
-Can they actively place their foot into correct position while sitting?
Sensation/Proprioception and Inattention/Neglect and sequencing:
-Ask pt if they can feel the foot position in sitting
-Joint position sense test in knee and ankle
- Tactile sensation test of foot
-Observe whether patient is paying attention to affected side
-Does cueing/feedback (eg. taped squares), help pt improve foot placement?
Reduced trunk forward lean Hypothesis
ROM:
-Lack of passive ROM in hip flexion
Strength/Weakness:
-Lack of concentric hip flexor activation initially
-Lack of eccentric hip extensors to control forward lean
-Lack of eccentric knee extensors and ankle PFs to load the affected leg and control the anterior movement of the knee during the trunk forward lean prior to thigh off.
Proprioception/sensation:
- Lack of proprioception and sensation of the affected leg
- Lack of vertical perception
OTHER:
- Dizziness, fear of falls, pain etc.
Testing Strategies for reduced trunk forward lean
ROM:
-Test PROM in hip flexion in sitting or supine
Strength/Weakness:
-Test concentric hip flexor activation to initiate trunk extension in sitting. Can they initiate the forward lean at hips while keeping the trunk extension in sitting? If unable, can they sit upright and hold the ant. pelv tilt w/o back support.
-Test ecc hip extensor activation to control forward lean- can they control the trunk forward lean at hips while reaching forward in sitting. How far can they reach forward? Can they do it with speed?
-Test eccentric knee extensors and ankle PFs activation to load the leg and control the anterior movement of the knee coupled during the trunk forward lean.
Proprioception/sensation/inattention/neglect of affected leg:
-Ask pt if they can feel the weight on the affected leg while leaning forward.
- Joint position sense of knee and ankle
- Tactile sensation testing of foot
Observe to check if pt is paying attention to affected side while leaning fwd.
-Use of cueing/feedback (eg. forward reach to target, use of scale under affected leg etc.) helps improve trunk fwd lean.
- Test verticality perception by sitting with wall on one side and check how they feel when they sit fvertically.
OTHER:
- Dizziness, pain, fear of falls - observe nonverbal expressions as well as subjective examination
Lack of Anterior Movement of the Knees Hypothesis
ROM:
- Lack of passive ROM in ankle DF
Strength/weakness:
-Lack of eccentric ankle PF activation to decelerate the forward momentum as the trunk and knees move forward
-Secondary to inability to perform trunk forward lean to create the fwd momentum
Proprioception/Sensation:
- Lack of proprioception and tactile sensation of affected leg
-Inattention/neglect
-Fear of falls; Pain, etc.
Sequencing/coordination:
- Inability to coordinate the activation of ankle PF with other muscles (hip and knee extensors) activity at and around the thigh-off period
Testing Strategies for lack of Anterior Movement of the Knees
ROM:
-Test PROM ankle DF - check in sitting and ensure there is 20deg ankle DF +/- apply weight if PF muscles are stiff
Weakness/Strength:
-Test eccentric ankle PF activation around thigh off for STS - Can they control the anterior movement of the knee in the context of performing the whole task of STS in even WB? Can they do it with cues (eg. target for knees before rising/instruction/demonstration?)
-If difficult, can they do it with <50% WB on affected leg?
-If difficult, in the context of the whole STS performance, can they load the affected leg and control the ant. movement of the knee when they reach forward out of BOS (towards 140% arm length). Use scale to monitor the loading of the affected leg. Can they do it with speed?
Also you could use less specific testing strategies to check the ankle PF activation in isolation (eg. tilt table calf raise).
Sensation/Proprioception and inattention/neglect:
-Ask the patient whether they can feel the knee moving forward and the weight on the affected leg while leaning forward out of BOS. Joint position sense test / ask pt.
-Tactile sensation of the foot
-Observation to check whether the use of feedback / cueing (eg. forward reaching target, use of scale under the affected leg) helps to improve the ant. movement of the knee.
OTHER:
-Pain, fear of falls, observe non-verbal as well as subjective examination
Lack of Hip Extension in Rising and Final Standing Hypothesis
Weakness/Strength:
-Lack of concentric hip extensor activation to rise then isometric at 0deg hip extension in final standing even WB
-Inability to coordinate the activation of hip extensors with other muscles (knee extensors and ankle PFs) activity during the rising phase
-Secondary to inability to perform another component of the STS (i.e. due to the lack of ant movement of the knee, causing the hip to stay behind in flexion
-Lack of postural adjustments required to rise and stand
-Lack of passive ROM in Hip Extension
-Lack of proprioception and tactile sensation of the affected leg
-Inattention/neglect
Testing strategies for Lack of hip extension in rising and final standing
ROM:
-Test passive ROM in hip extension: check in standing or sidelying
Weakness:
-Test hip extensor activation during rising phase. Can they extend the hip to rise and maintain hip extension at neutral in final standing (even WB) during the while STS performance?
-Measure the seat height to evaluate the level of activation in STS. If unable, can they do it with <50% WB on the affected leg?
OR can they do it with assistance? Measure level of assistance.
-Can they do it together with other muscles activity to control knee and ankle segments? If unable, can they control hip extension in isolation by eliminating the need to control other segments with assistance? I.e testing active hip extension control in final standing with assistance to hold the knee and ankle. Adjust the amount of weight bearing on the affected leg in standing.
-Less specific testing strategies: bridging or side lying hip extension
Proprioception/Sensation:
- Ask pt whether they can feel affected leg while hip extending during the rising phase
-Joint position sense test of hip, knee and ankle
-Tactile sensation test of foot
-Observation to check whether patient is paying attention to affected side during rising phase
-Check whether use of feedback/cueing (e.g hip extension target, use of scale under affected leg) helps improve hip extension in even WB during rising phase.
OTHER:
-Observation non-verbal expression, fear, pain etc.
Lack of Knee Extension in rising and final standing Hypothesis
ROM:
-Reduced hip extension range
-Lack of passive ROM in ankle DF
Weakness:
-Lack of concentric knee extensor activation then isometric at ~5deg knee flexion in final standing
-Lack of concentric ankle PF then isometric at ~5deg DF
Proprioception/Sensation:
-Lack of proprioception and tactile sensation of the affected leg
Sequencing:
-Inability to coordinate the activation of knee extensors and ankle plantarflexors with other muscles (hip extensors) activity during the rising phase
OTHER:
-Lack of postural adjustments required to rise and stand
-Inattention/neglect
-Fear of falls, pain etc.
Testing strategies for lack of knee extension in rising and final standing
ROM:
-Test PROM in ankle DF - check in sitting +/- apply weight if PF muscles are stiff.
Weakness:
-Test the knee extensor activation during rise phase by seeing if they can extend knee to rise and maintain the inner range extension at ~5deg in final standing (even WB) during the whole STS performance. Measure the seat height to evaluate the level of activation in STS. OR can they do it with assistance? Measure level.
-Test the ankle PF activation during the rising phase. Can they PF the ankle as the knee extends to rise and achieve the final vertical standing alignment of 5deg Knee F and 5deg ankle DF (in even WB) during the whole STS performance?
Measure seat height. If unable to do, can they do with <50% WB on affected leg. Can they do with assistance? Measure level.
Sequencing:
-Through whole STS, test ability to coordinate the knee extensors and ankle PFs to achieve proper knee extension in rising.
- If too weak to perform whole STS, can they just maintain final standing alignment with active isometric inner range knee extension and PF after assisted to rise? If unable to coordinate with hip segment, can they extend knee and PF ankle in isolation eg. tilt table knee bends/calf raises.
Proprioception/sensation:
-Ask pt if they can feel affected leg while knee is extending during rising phase. Joint position sense tests, tactile tests of foot, observe whether pt pays attention to affected side. Check whether cueing/feedback (eg. scales under affected leg) help improve hip extension in even WB during rising.
OTHER:
-Pain, fear of falls, check facial expression/non-verbals as well as subjective examination.
Lack of weight bearing on the affected leg hypothesis
Can be due to any of essential components.
- lack of PROM in ankle DF or Hip Ext or knee ext.
- Lack of hip abductor activation to control medio-lateral postural sway in standing
- Coordination
- Lack of proprioception and tactile sensation of affected leg
- Inattention/neglect / lack of verticality perception
-Fear of falls, pain etc.
