neuro practical skills Flashcards
How would you stretch a patients calf? who may need this?
supine OR SU with knee flexion:
- hold under TA and cupping the heel > foot against your forearm > holding their knee in extension > gentle pull 20-30s
- ensure they complete at home > feet against a wall into DF > towel around foot and pull
~ Thomas - Parkinson’s
~ potentially Millie - MS
How can you stretch the hip flexors? who may need this?
prone:
- hand on glute > grasp leg with arm > gently pull up > 20-30s
- home exercise > supine shuffled to edge > drop leg over side of bed for stretch
side lying:
- hand stabilising hip > hold under inner thigh > extend hip backwards
- to add knee extensors > flex the knee slightly
~ Millie - MS > P1
~ Thomas - Parkinson’s > flexed posture
How to position a stroke patient with hemiplegia in supine? issues may occur > how to adjust and fix position? positive and negatives?
supine:
- prevention of shoulder girdle retraction > likely to fall back in SU > shortening ST > use V shaped pillows and pillow on top for comfort
- prevent dropping of pelvis in effected side also causing falling out or external rotation of low toned leg > pillow will elevate too much leading to asymmetry > use a rolled towel on affected side for smaller correction
- shortening of TA from lying > pillow against end of bed to introduce more plantar grade position > long term PT may need to use a splint
- hyperextension of the knee > pillow propped under knee > high awareness and checking this is not enabling ST shortening in hamstrings
+ comfort
- not very functional position > bring top of bed up so PT is in long sitting remaining symmetrical
How to position a stroke patient onto their AFFECTED side? issues may occur > how to adjust and fix position? steps?
AFFECTED side:
- aware not to bring PT on top of there shoulder > bony point > discomfort > more prone to injury > bring shoulder forward to rest more onto scapular
- bend unaffected leg so the foot is flat > and unaffected shoulder cross body AD-duction > turn head to affected side > guide hip and trunk over (ready, set, roll) > bring pelvis back if needed > wedge a pillow under side > pillow between knee to foot
+ free to use and move unaffected arm
+ affected arm is supported > increase sensation due to pressure
How to position a stroke patient onto their UNAFFECTED side? issues may occur > how to adjust and fix position? steps?
UNAFFECTED side:
- less PT assisted due to weakness in affected side
- support shoulder onto scapular not on top
- bend leg > cross body arm > roll > wedge pillow into back and between knee to foot
- gravity induced oedema (swelling) if affected arm is dropped down > pulling on arm > what is most comfortable e.g. pillow or two under arm and towel under hand
+ good position as a therapist > affected side is available for Rx e.g. ROM, hip into full extension
- PT loses activity and function HOWEVER may encourage use of affected UL as they cannot use unaffected
How to position a stroke patient in a chair? issues may occur > how to adjust and fix position? steps?
- may be slumped, side flexed to one side > muscle shortening and increased tone
- wheelchairs may be more challenging to support patient (back is flexible) but can encourage muscle activation also easy to transport PT
- POSITION OF PELVIS > sit PT forward > shuffle then towards the back of chair > evenly distribute weight
- anterior tilt and Lx extension > bring pillow behind for more support aiding extension > if lacking Lx extension add a rolled towel as Lx roll
- wedge a blanket or towel in either side to reduce affects of gravity dropping into one side
- 90 degrees in hip, knees and feet
- avoid traction on arms > gravity pulling down > pillow on lap with V shaped pillows across forearms > if needed place affected side onto a side table with hand towel
What is clonus in clinical presentation?
positive result leads to oscillations of the foot:
- involuntary muscle contractions in foot
- uncontrolled, rhythmic shaking when foot moved into DF and PF a few times before rapidly (brisk) stretching into DF
What is an associated reaction?
an involuntary movement or tonal increase, seen in affected extremities when unaffected side is resisted OR high effort in made in an affected extremity causing irregular movement elsewhere in that side (based on increased effort)
What occurs in a patient with a grasp reflex? who may present this?
- involuntary flexion-adduction involving hand and digits
~ Parkinson’s patients
What is a positive support reaction? how can it be presented and in who?
- postural reflex > extension of foot and leg on contact of the ground
- two caused mechanisms: 1. a proprioceptive stretch of intrinsic muscles within foot mixed with 2. external stimuli of pressure on foot from weight bearing > causing PF and inversion in response
- toe off > load and pressure is at its greatest
- foot forced into extension where DF is needed into the swing phase > cannot bring pelvis weight over extended LL > may cause knee hyperextension and hip retraction loosing neutral alignment
patients may…
- volt over limb > pushing over extended limb
- keep weight on unaffected side > staggered unrelease of weight from unaffected side > no lateral weight shift from UN.A to A.
- all of the effort required to take a step may introduce associated reactions in UL or LL (compensation elsewhere)
How would you treat a positive support reflex?
- focusing on desensitising the foot (trigger of PSR)
- soft tissue mobilisation > stretching
- joint mobilisation > accessory movements
- position of limb and gradual weight bearing
- PT in supine > mobilise BOS (ball of foot) which will be very sensitive > work with as much pressure without initiating reaction > circular motion to work tissues
- due to WB on inverted and PF foot > medial gastroc. and soleus get tight > calf stretch against your forearm
- ROM in foot and ankle
- move PT to a seated position (neutral and aligned) > gradual WB > A1 support medial knee into neutral and around ankle
- lateral and anterior direction to increase WB > A2 support under UL, PT arm resting on you > other hand free to support back > slowly move trunk towards you with PT reaching
- AP weight shift > same arm position but in flexion > rock weight back and forth > also reach up or down (or across with unaffected arm)
- gradually increase height of plinth into standing position > introduce different stances > eventually into gait re-education > contours of floor, terrain, footwear, steps
How would you stand a LOW tone patient? problems in S2S? presentation? steps?
- ensure equal weight bearing > rather than leaning and WB onto the unaffected side
- lack of control in glute and quads > struggle to come up into hip extension, maintain knee extension and coordination of hip and knee
could present…
- knee hyperextension so they feel more stable and retracting the hip
- when coming up with the hip the knee may buckle and give way
- one therapist on unaffected side, one close to the floor gripping knee and hip for activation OR knee and foot with a different therapist at the hip depending on the patient and third therapist under the axilla (armpit) and supporting back
- ready, set, stand
- if able introduce weight transference to ES
- if loss of extension > facilitatory activation > tapping, stroking and squeezing muscle
How to stand a HIGH tone patient? issues? presentation? steps?
- overactivity could be in extensors and abductors in LL
could present…
- when standing they shift to unaffected side, with affected side going into plantar flexion (some inversion), hyperextension of knee with hip retraction and trunk flexion
- anterior pelvic tilt, trunk extension, hip and knee coordination, assistance at foot to ensure PF and inversion wont occur
- therapist on unaffected side ensuring no increased WB, one supporting axilla and externally rotating arm encouraging opening up and extension of trunk, one at knee (prevent HE) and foot (effective WB and prevent PF and inversion)
- ready, set, stand
- therapist under axilla can put hip behind PT glute to maintain extension and not retraction
- check symmetry > inhibit abnormal patterns
How was you treat EARLY stage BALANCE re-education?
early stage rehab of balance is largely EQUILIBRIUM reactions and some early RIGHTING reactions
- ER ~ automatic postural corrections keeping us in centre of BOS
- RR ~ as COG moves closer to edge of BOS the body rights itself back to midline
- anterior pelvic tilt and Lx extension and ability to move trunk on top of pelvis
- recruiting upper trunk extension through proximal key points at sternum and U Thx and/or distal point at shoulder girdles
ER - take PT into slow and controlled facilitated anterior and posterior pelvic tilt flow
- lateral pelvis movements (minimal movement as ER) > support under axilla > encourage slight lift of opposite glute maintaining stretched side
- integrate movements when recruitment is independent > shoulder flexion up and back down > up again with hand to head > hand to touch therapists diagonally each way
RR - same lateral movement and facilitation with a larger weight shift, lifting glute higher off and increased lean
- integrate greater distance in movements unlike ER, taking PT closer to edge of BOS > use objects
What would you change about BOS for a high or low tone patient?
HIGH tone patient - wider BOS > lower COG > increasing balance to relax muscle activity
LOW tone patient - smaller BOS > higher COG > decrease support to encourage muscle activation
