NM Final Flashcards
functions of semicircular canals and otolith organs
semicircular canals: sense angular motion
otolith organs: sense linear movement
TUG cutoff scores
- 30 seconds=needs assistance for mobility and ADL’s
- ->12 seconds=fall risk
Difference in children’s TUG
- touch target
- repeated instruction
- no arms on chair
- knee angle 90 degrees
- time begins when child leaves the seat and not on “go”
FRT normal ranges
~14 inches (more for men, less in elderly)
Berg Balance cutoff scores
0-20 high fall risk
21-40 medium fall risk
41-56 low fall risk
45 is fall cut off risk for community dwelling, less than 40 predicts 5x more likely to fall
-in high scores, each 1 pt drop associated w/ 3-4% fall risk
MDC for berg
change of 8 points
Differences of pediatric balance scale
- age 5-15 w/ mild to mod motor impairment
- same items from Berg but modified
Activity Specific Balance Confidence Scale
-50-80%= somewhat impaired
66% or less= high risk for falling
-self report on specific items
Falls Efficacy Scale
-report on self confidence in ability to accomplish specific tasks
POMA
-Balance portion and gait portion- total score is 28
Postural Assessment Scale in Stroke (PASS)
-maintaining a posture
-changing posture
0-3 score for each item
clinical test for sensory interaction in balance
Traditional: 6 sensory conditions: firm surface (EO,EC,dome) foam surface (EO,EC,dome) (can be modified to just 4 without use of dome
6 categories of BESTest
- biomechanics constraints-pain, alignment
- stability limits-functional reach, etc
- anticipatory postural adjustments- sit to stand, etc.
- postural responses- compensatory steps, etc.
- sensory orientation- eyes open, eyes closed, etc.
- stability in gait- change in gait speed
Interventions for balance
- determine contributors
- remediate, compensate, or prevent
- adapts gait to changing tasks and environmental contests
balance is dynamic or static?
DYNAMIC- utilizes vision, vestibular and somatosensory systems
-integration of all info in CNS
Top 3 outcomes reported for children/young people
interpersonal relationships
community and social life
emotional well-being
top 3 outcomes reported by parents
community and social life
gaining independence
emotional well-being
general measures of participation/activity
- patient specific functional scale
- goal attainment scale
- FIM and Wee FIM
- Activities-specific Balance confidence scale
Stroke specific measures of participation/activity
-SIS
Pediatric specific measures of participation and activity
- CAPE (Children’s assessment of participation and enjoyment
- PAC- Preference for Activiities of Children
Activity measures for CP in Pediatrics
-AIMS/PDMS/BOT-2
GMFM*
PEDI*
Wee FIM
GMFM
evaluate change in motor function fibe areas: lying/rolling crawling/kneeling siting standing walking/running/jumping orthotics/ad can be used 5 mo to 16 years 88 item (cp/ds) or 66 item (cp only-scored w computer program)
PEDI
standard and scaled score for 6 month-7.5 years
can use scaled scores (not standard) for children over 7.5 years
-Interview assessment- repondent is parent or caregiver
3 domains: self-care, mobility, social function
PEDI CAT
comprehensive clinical assessment of key functional capabilities and performance
-computerized adaptive testing
Pediatric specific QOL measures
CP QOL
CPCHILD
PedQL-all ages
3 modes of interventions for PT goals
remediate: minimize effects of impairments of body structure or function
prevent: limit secondary impairments or conditions
compensate/accommodate: maximize gross motor function using strategies for impairments and activity limitations that aren’t likely to change
GMFCS levels
level I: walks without restrictions; limitations in more advanced motor skills
level II: walks without devices; limitations in walking in the community
level III: walks with the use of devices; limitations in the community
level IV: self mobility limitations; children are transported or use power mobility outdoors and in community
level V: self mobility is severely limited even with use of technology
To what age would it be best to remediate/compensate/prevent?
Remediation and prevention for level IV/V until 7 yrs., Level II/III until about 8 years, Level I until about 11 years. May begin more compensation after, and continue prevention
Different categories in which therapy can be provided in regards to amount of visits
- Intensive (3-11/wk)
- Weekly/bimonthly
- monthly or less often at regularly scheduled intervals
- Consultative episodic or as needed
4 continuums of care
Early intervention: focus on parent education- goals usually 6 months
school based: PT is related service, focus on access to education- goals usually 6 months to 1 year
inpatient: highest intensity, often post-surgical, 2x/day gals are days/weeks
outpatient: variability in dosage, goals 4-12 weeks
Roles of PT in acute stage post stroke
-prevent another stroke, prevent complications, general health, mobilization, resume self-care, emotional support to patient/family
Roles of PT in post-acute-inpatient rehabilitation after stroke
-assessment and recovery of physical and cognitive function, begin compensation for residual impairments
Regions of brain injury by ischemia
penumbra-innermost area- location of infarct
peri-infarct
normal surrounding area: undamaged tissue can overtake roles, plasticity
Phases of recovery from stroke (physiological level)
- initial phase: cerebral edema decreases, damaged tissue is absorbed, blood flow improves
- reparative phase: regeneration via collateral sprouting, reorganization of neuropathways
Penumbra
site of permanent damage from infarct
When does the greatest recovery occur following a stroke?
-neurologic recovery occurs in the first 3 months after a stroke- further recovery may take pace 6 months to one year later, but some motor function must be preserved in order for this to happen
After what time frame is it termed “chronic stroke”
-after 6 months
In early rehabilitation from stroke, what forms of intervention take priority ?
remediation: increase force production, mobility training, primary impairments
In later rehabilitation from stroke, what forms of intervention take priority?
-compensation: gait aids, orthotics, modify mobility Istill address secondary impairments, independent activities)
Prognostic factors regarding sitting balance in stroke
-predictive of walking ability after 6 months: initial sitting balance most correlated standing, walking, stair climbing at 6 months post-op
4 positive prognostic indicators for responding to therapy
- initial return of movement within the first 2 weeks
- active participation by patient
- specificity of and functional task oriented training
- acuity of stroke
7 negative prognostic indicators following stroke
- coma at onset
- poor cognition
- severe aphasia
- no motor return within one month
- inability to sit unsupported
- incontinence 2 weeks s/p CVA
- depression
- visual-perceptual-spatial disorders
pusher syndrome
- ipsilateral pushing/contraversive pushing
- 10% of those with CVA have pusher syndrome
- thalamic damage
- take 3.6 weeks longer to reach functional outcome levels
- patients lean and actively push aways from non-hemiparetic side
- forceful resistance against any passive attempts to correct the tilted posture
3 items for clinical assessment scale for contraversive pushing
-spontaneous body posture
-abduction and extension of non-aretic extremities
-resistance to passive correction of tilted posture
Items assessed in sitting and standing- max score is 6, which indicates severe impairment
Intervention for pusher syndrome
- get patient to realize disturbed perception
- explore surroundings and body’s relation to surroundings- use visual aids
- learn movement to reach vertical body position
- maintain the vertical body position while performing other activities
Cutoff scores for fugl meyer indicating severe prognosis
> 80 mild
56-79 moderate
36-55 moderately severe
BI cutoff scores
100 is complete functional recovery
>60 is “assisted independence”
Normative velocity values for gait for independent community ambulation
- 332 meters (6MWT)
- 1.2 m/s=2.68 mph
Normative values for household ambulation
.4 m/s
limited community ambulation .4-.8 m/s
full community ambulation .8m/s (different from above)
Cutoff scores for orpington prognostic scale
- 2 req. LTC
3. 2-5.2 intensive rehab
Heman’s 6 stages of movement
- Initial conditions: posture/interaction, etc
- Preparation: stimulus identification/response selection
- Initiation: timing, direction
- Execution: amplitude, direction, speed
Termination: timing, accuracy - Outcome: achieved?
How do you prioritize the key points of control?
proximal to distal
What is the progression sequence for strengthening?
Isometric, eccentric, concentric
Items to prevent early in recovery
- learned non-use
- injury
- join subluxation
- skin breakdowns
- falls
Items to prevent later in recovery
- deconditioning
- contractures
- falls
- fractures
- pneumonia
Key points for remediation
-muscle activation and force production: repetitious exercises, facilitation techniques, NMES
Remediation involving stability and mobility
Stability: static exercises such as seated activities, orientation to midline, standing progression
Mobility: dynamic exercise such as correcting perturbations, reaching, weight shifts
Remediation involving stability and mobility
Stability: static exercises such as seated activities, orientation to midline, standing progression
Mobility: dynamic exercise such as correcting perturbations, reaching, weight shifts
Aerobic activity recommendations
50-80% max HR
RPE 11-14 (6-20 days per week)
3-7 days per week
20-60 minutes per session
Reasons to support use of body weight support treadmill training
- intensive task-specific locomotor training
- repeated segmental sensory inputs
- may facilitate cortical and subcoriacl organization
- minimizes delay in gat training
Limitations to BWS treadmill training?
- equipment
- often two people needed
- differences in walking
CIMT in subacute phase for CVA
- 14 consecutive days of physical restraint on the less affected UE
- restraint worn for 90% of waking hours
- 6 hours/day, 5 days/week intensive training
modified CIMT
-1 hour PT/OT/day
-3 days/week
-10 weeks
unaffected UE restrained 5 days/week for 5 hours
FES
DF assist during swing phase of gait
Increase motor unit recruitment and rate of firing
Evidence for prevention of shoulder subluxation when used on trapezius
Overall PT goals for CP intervention
Increase participation thru
- remediation: minimize effects of impairments
prevent: limit secondary impairments/conditions - accommodate: maximize gross otor function
- *Enhance individual’s quality of life
suggested frequency of visits for CP
-younger children w diplegia=1-5x/wk, older more episodic
-4x/wk for 4 weeks with 8 weeks off
2/wk for 6 mo
**2x weekly better than twice monthly
When should the discussion about duration and discharge begin?
at the 1st visit!
Green light interventions
- activity focused/context-focused/goal-directed functional therapy
- fitness training
- constrain induced movement therapy
- bimanual training
- castin for improved ROM
- home programs for improving motor performance or self-care
Activity focused/goal directed functional therapy
- long term retention
ex: moving coffee table in order to encourage extra step towards table
fitness/aerobic training for CP
improves aerobic conditions, but benefits do not last after training is over, so want candidates that plan to continue for the lifetime
5 components of home programs for improving motor performance or self care
- develop collaborative relationships
- set mutually agreed upon measurable goals
- select therapeutic, routine-based activities
- support with communication and reinforcement
- evaluate outcomes
5 components of home programs for improving motor performance or self care
- develop collaborative relationships
- set mutually agreed upon measurable goals
- select therapeutic, routine-based activities
- support with communication and reinforcement
- evaluate outcomes
Yellow light interventions
Assistive technology: standing devices, whole body vibration, virtual reality, seating/positiong Conductive education early intervention for motor outcomes E-stim hippo therapy and hydrotherapy orthoses therasuits treadmill training stretching strength/muscle power training
time that must be spend standing in standing devices to see benefits
60-90 minutes
Best way to utilize strength training for children w CP
strengthen 1 jt. over 2 jt. muscles, out of synergy if possible
What can be used if the primary impact of spasticity limiting function conservative approach not working?
botox, baclofen, SDR
what can be used if hypo extensibility limiting function cannot be managed conservatively?
serial casting, orthopedic surgery
What 3 muscle groups should be focused on in pts with CP?
glut max/med, quads/hamstrings and ankle df/pf
Red light interventions
craniosacral therapy neurodevelopment treatment : kinesiotape joint mobilization non-pt treatments (stem cell, hyperbaric O2)
In what situations is NDT useful?
improving independent functional movement for infants with posture movement dysfunction during first year after birth- NDT based trunk protocol
In what situations is NDT useful?
improving independent functional movement for infants with posture movement dysfunction during first year after birth- NDT based trunk protocol
diagnoses to consider use of orthotics
CVA, MS, TBI, SCI, ALS, post-polio, lumbar radiculopathy
types of orthotics
ankle-foot orthoses (AFO) knee ankle foot orthoses (KAFO) hip-knee ankle foot orthoses (HKAFO) supramalleolar orthoses (SMO) FES
Indications for solid AFO’s
- ankle instability
- equinaovarus
- moderate-sever pes planus
- genu recurvatum
contraindications to solid AFO
sever genu recurvatum, good knee strength
Indications for hinged/articulating AFO
- foot drop
- genu recurvatum
contraindications for hinged AFO
poor knee control
concerns about extra weight/bulk
indications for posterior leaf spring
foot drop, TA weakness
contraindications for posterior leaf spring
ankle instability, genu recurvatum, severe PF spasticity
indications for flexible AFO
-mild foot drop, need for slight DF assist, mild ankle varus/valgus
contraindications for flexible AFO
severe ankle instability, knee instability
indications for ground reaction AFO’s
foot drop, knee instability, crouch gait pattern
contraindications for ground reaction AFO’s
genu recurvatum, concerns with bulk
indications for carbon fiber AFO’s
foot drop, poor push-off
contraindications for carbon fiber AFOs
ankle instability, poor knee strength
considerations of KAFO’s
-poor knee and ankle stability, use for functional standing, for therapeutic walking
considerations of HKAFO’s
increased proximal deficits, mostly used in therapeutic settings, used for very slow
considerations of SMO
-only helps w foot position during gait
way help increase WB time on affected side, less bulk
Areas improved using an AFO after stroke
- walking velocity and symmetry of spatial parameters of gait (stance asymmetry, etc. )
- gait speed, balance, and mobility
Any evidence to support that FES is superior to AFO?
no, but research revealed that it was often more preferred
Any evidence to support that FES is superior to AFO?
no, but research revealed that it was often more preferred
What do the majority of AFO users in CP use the AFO for?
- function and ROM
- greatest use in GMFCS level 1 and in boys
What is assistive technology
devices and services that enhance the abilities/participations and eliminates functional limitations
what is augmentative and alternative communication?
means other than speech to assist w communication
augmentation: supports existing speech to assist in communication
alternative: systems intended to be primary communication system
5 items included in an IEP for IDEA
- evaluation
- obtain device/service
- device functional, adapted to student
- coordinated services-funding
- training child and family
- training school and other relevant personnel
Who makes up the core team in the selection process of AT?
users: client/family
PT, OT, ST, SLP, rehab engineer, rehab technology supplier
Things to consider when writing letter of medical necessity
- talk to team and family about expected benefits/necessity
- look at websit for equipment
4 steps of quality improvement process
plan, do, study, act
percentage of people w PD?
1.3-1.5% of people
cardinal features of PD
resting tremor, bradykinesia, rigidity, postural instability
positive affects of exercise on PD
-increased synaptic plasticity, enhanced cognitive ability, enhanced learning and memory
repaire degeneration
prevent further degeneration
general aerobic activity for aging adults
20 minuts 3x/week vigorous OR 30 minutes 5x/week moderate
guidelines for muscle strengthening in aging adults
- 8-10 exercises, 10-15 reps
- 2x/week non consecutive days
guidelines for flexibility training
8-10 exercises; hold 15-30 sec
2x/week at least
Balance activity
challenging, but successful, daily
what can cardiorespiratory training improve following stroke
vo2 peak, 6 MWT, SF36, la, but lack of retention improvements
activity for children?
60 min mod-vig activity
spasticity
exaggerated stretch reflex due to a loss in supraspinal inhibition/control resulting from an UMN lesion- velocity dependent
muscle spasm
often follows musculoskeletal injury and inflammation. tissue damage increases nociceptive input to Ia afferent resulting in excessive activation of alpha motor neuron. the increase in muscle contraction (tonic) increases metabolites which increase lactate, pain and the cycle repeats
diazepam
release of GABA-A in spinal cord- reduces spasticity
oral or parenteral
adverse: sedation, hypotension, dizziness, fatigue
AND reduces muscle spasms
first line agents for acute pain
NSAIDs: recommended for up to 2-4 weeks in patients w not increased risk
acetaminiophen is less effective than NSAIDs, but can be a good option for patients without hepatic compromise that cannot tolerate NSAID’s
Baclofen
- acts on presynaptic GAVA-B receptors at excitatory synapses in spinal cord
- reduce release of excitatory NT’s
- REDUCES SPASTICITY
- oral/intrathecal
- potential for withdrawals if stopped abruptly
- side effects: sedation, hypotension, dizziness, fatigue
Dantrolene sodium
acts directly on skeletal muscle: binds to ryanodine receptor
- REDUCES SPASTICITY
- oral- can be slower/less complete absorption, but only option
- side effects: hepatotoxicity, monitor liver function
Tizanidine
- agonist at a2-adrenergic receptors
- reduces spasticity- useful via oral route for treatment of spasticity of spinal and cerebral origin issues
- Oral
- adverse effects: hypotension, dry mouth, asthenia (loss of strength)
Botulinum toxin
- block of ACh release at NMJ junction produces paralysis and muscle relaxation (not complete)
- controls severe spasticity from various disorders
- injected locally into specific muscle groups
- higher doses more frequency administration may result in neutralizing antibodies
carisoprudol/cyclobenaprine/methocarbanol
- exact mechanism of action uncertain, but probably involves gnereal inhibition of polysynaptic reflex pathways in brain stem and spinal cord
- reduces muscle spasm
- oral/parenteral (3-4 doses/day)
- all of agents can cause tolerance and physical dependence if long-term
What does the sudden initial reduction of spasticity increase the risk of?
falling episodes in patients previously relying on extensor spasticity in lower extremities to assist in ambulation
what specific side effect is likely with all muscle relaxants/anti spasticity meds that is important to PT?
sedation-sometimes must be accommodated in a rehabilitation program: may require scheduling treatments at a time of day that minimizes effects
what can aggressive PT in conjunction w these meds allow for?
discontinued use of agents as soon as possible due to sedative and tolerance-developing properties
