PTA Neuro - Hemiplegic Practical Flashcards
When do you facilitate?
when there is not enough tone or motor control
When do you inhibit?
when there is too much tone
Which bed position is most therapeutic?
side-lying on the involved side
What is the measurement scale for balance?
Good
Fair
Poor
What is the measurement scale for coordination?
Impaired
WNL
What is the measurement scale for functional status?
I SBA CG MIN A MOD A MAX A DEP \+1
when in doubt…
…weight bearing
things to remember when preparing the area/environment
chair placement armrest/ footrest chair locked gait belt shoes/treads height of surfaces call bell (at end) clear the path
Important thing to remember with interlaced fingers
the thumb of the involved UE is on the outside
- a bit of abduction to reduce tone
List 5 important objectives for Hemplegic positioning
lying, sitting, standing
- increase weight bearing on involved side
- increase trunk rotation
- increase elongation of trunk on involved side
- facilitate separation of trunk and pelvic motor control
- maintain scapular and pelvic protraction (on involved side)
List 5 goals for positioning of a hemiplegic patient in side-lying or supine
- prevent contracture/maintain normal ROM
- minimize abnormal tone
- stimulate motor function
- increase sensory input
- prevent skin breakdown
describe side-lying on Involved side for patient with hemiplegia
- most therapeutic
- head and neck in neutral (pillow or two)
- Involved UE:
- scapula protracted (manually)
- shoulder flexed to 90
- arm supported on pillow (hand higher than shoulder)
- elbow extended
- forearm supinated
- neutral wrist
- fingers extended (cloth or splint)
- thumb abducted
- Involved LE:
- hip extended
- knee flexed slightly
- ankle neutral (supported off bed with pillow)
- nothing touching ball of foot (avoid PF)
- use boot to encourage DF
- pillow folded and tucked behind back
- Uninvolved LE:
- hip and knee flexed
- as many pillows as needed to prop uLE to neutral
describe side-lying on Uninvolved side for patient with hemiplegia
- head and neck neutral (pillow or two)
- folded towel under ribcage for neutral trunk/elongate involved side (pre-positioned)
- Involved UE:
- scapula protracted (pillow prop)
- should flexed to 90 on pillow
- elbow extended
- neutral forearm (hand higher than arm & shoulder to prevent swelling)
- finger extended
- thumb abducted
- Involved LE:
- hip & knee flexed slightly on pillow(s)
- pelvis protracted
- ankle neutral with towel to keep malleolus off bed
- nothing touching ball of foot (avoid PF)
- use boot to encourage DF
- pillow folded and tucked behind back
describe lying Supine for patient with hemiplegia
- head, neck, trunk in midline - one pillow
- small towels beneath involved scapula and pelvis for protraction
- Involved UE:
- on a pillow, hand higher than shoulder
- shoulder ER
- elbow extended
- forearm supinated
- wrist neutral/slightly extended
- fingers extended with towel or splint
- thumb abducted
- Involved LE:
- pelvis protracted (small towel), neutral rotation
- thigh neutral (towel prop) (avoid lateral rotation)
- hip, knee flexed slightly (pillow prop)
- ankle neutral
- heel not touching bed
- nothing touching ball of foot (avoid PF)
describe wheelchair positioning for patient with hemiplegia
- head, neck neutral
- head, neck symmetrical
- spine midline
- hips equally weight-bearing (so, square)
- Involved UE:
- scapula protracted (arm forward with elbow supported on lap-board or trough)
- wrist neutral
- fingers extended
- thumb abducted
- Involved LE:
- hip, knee flexed to 90, neutral rotation
- femur parallel to floor
- ankle neutral, DF
- Uninvolved LE free to steer, no leg/footrest
name two key points of control for spasticity in a patient with hemiplegia
scapula
pelvis
UE tends to spasticity in which muscles?
flexors
so, position in extension
LE tends to spasticity in which pattern?
extensor pattern
why is pelvis positioned in “protraction”?
to inhibit extensor pattern in LE
in sitting, what will involved side tend towards?
shortening
- need to work to keep it elongated
describe UE Flexion Synergy
scapular retraction or elevation * shoulder ER * shoulder abducted to 90 elbow flexed * forearm supinated wrist flexed fingers flexed
describe UE Extension Synergy
scapular protraction * shoulder IR * shoulder adducted elbow extended * forearm pronated wrist extended fingers flexed
describe LE Flexion Synergy
hip flexed hip abducted hip ER knee flexed to 90 ankle DF foot inverted toes extended
describe LE Extension Synergy
hip extended hip adducted hip IR knee extended ankle PF foot inverted toes flexed
name activities/exercises good for both
- trunk and pelvic motor control
- balance
in sitting
- A-P pelvic tilts for neutral pelvis (leads to upper trunk extension for erect posture)
- lateral weight-shifting (leads to sitting properly midline)
- weight-bearing on UEs
- upper trunk rotation w/i-UE cradled (leads to dynamic sitting balance)
- alternating isometrics (build stability -> balance) (slower than rhythmic stabilization)
- rhythmic stabilization (build stability -> balance) (slower than perturbations)
- rolling ball with iUE
- reaching activities (cone stacking)
- chopping/lifting (for UE and trunk) (pt watches with his eyes)
- knee -rolling pin, towel slide, reciprocal knee extension
- ankle - tapping, heel-toe, kicking ball
- marching in place
- scooting forward
- scooting laterally
things to think about during trunk and pelvis balance and motor control
- use the string imagery for sitting tall
- cue to sit tall always
- think about where I put my hands
- don’t push or pull, only touch to facilitate
- I can sit beside pt
- I can hold pt elbow
- in PNF-type, I stand in diagonal
What is the difference between Alternating Isometrics and Rhythmic Stabilization?
In AI, resistance is applied on the same side of the joint
In RS, resistance is applied on opposite sides of the joint
What is the same between Alternating Isometrics and Rhythmic Stabilization?
- both encourage stability of the trunk, hip, and shoulder girdle
- no motion should occur from the pt; pt should simply resist the therapist’s movements
- The therapist’s movements should be smooth, fluid, and continuous
- For example, the patient can be in a sitting, kneeling, half-kneeling, or standing position when the therapist applies manual resistance to the shoulders
describe Alternating Isometrics
- SLOW and CONTROLLED
- looks kind of like MMT
- “don’t let me push”
- antagonistic groups: side-to-side or front-to-back
- build up & down
describe Rhythmic Stabilization
- rapid and quick (but not as quick as perturbation)
- pt holds position while PTA pushes all over (?)
- looking for co-contraction all around
- “You are a mountain”
- side-to-side, forth-and-back, rotation
progression for sitting balance
- sit up
- front-to-back plane
- side-to-side plane
- rotations
- add challenges
best thing to keep in mind for everything
“what is the goal?”
what is process for working on sit -> stand?
- raise mat a bit to facilitate activity
- scoot to edge as needed
- sit up tall (erect posture)
- feet a bit behind knees (or uUE a bit forward to increase WB on iUE)
- stabilize iUE with uUE
- flex at hips (lean, lean, lean)
- press through feet
- when hips clear mat, extend through ankles, knees hips to stand upright
What are PTA cues for sit -> stand?
- cues forward/downward femur
- cues forward at pelvis or at scapula
- cues upright at upper chest
What are PTA cues for stand -> sit?
- shoulders forward
- hips back
name therapeutic activities to increase trunk motor control from supine
- bridging w/approximation
- lower trunk rotation
name therapeutic activities to increase LE motor control from supine
- Raimiste’s phenomemon for hip add- and abd-duction
- hip flexion with traction-facilitation
- ankle DF with hip and knee movements
- SLR with uLE while iLE in hooklying position
- bed mobility
name therapeutic activites to increase UE motor control from supine
- modified PNF diagonals (chop, lift) (because not so much trunk rotation)
- bilateral UE elevation
- bed mobility
describe chopping PNF
clasp hands
iUE start palm down, at opposite shoulder
chop on the diagonal
iUE ends palm up, by involved knee
- follow with eyes to also get trunk rotation
describe lifting PNF
clasp hands iUE starts palm down, at opposite knee lift on the diagonal iUE ends palm up, by involved shoulder - follow with eyes to also get trunk rotation
name activities to facilitate flaccid LE
- bridging (w/approx)
- raimiste’s
- passive ankle stretch
clues for cues
- be concise
- be clear
- attend to how you say it
- choose activity based on the deficit
difference between Traction and Approximation
Traction
- to facilitate initiation of flexion
- separate joint surface
- promote movement
- used where motion is pulling
Approximation
- to faciliate extension
- compress joint surface
- promote stability or maintenance of posture
- used where motion is pushing
Where might one apply Approximation?
- at shoulders to work on trunk control in sitting
- at pelvis to work on standing balance
- arm?
quick stretch: facilitory or inhibitory?
Facilitory
prolonged stretch: facilitory or inhibitory?
Inhibitory
What is the number one thing the PTA must remember?
To always let the patient do as much as possible.
Patient needs to do all the work!!
name activities for Pre-Gait, facing the table/support/barre
- two hands on the bar
- lateral weight-shift, with hands moving
- anterior-posterior weight-shift, stagger stance
- look over shoulder
- side-stepping
name activities for Pre-Gait, one hand on the barre
- lateral weight-shift
- anterior-posterior weight-shift, stagger stance, uLE first
- stepping out with iLE (toe sock)
- a-p weight-shift with step forward and back
- look over shoulder
when in doubt, think about how a baby develops
prone elbows quad tall kneel stand
CVA cane gait?
uninvolved
cane
involved
wheelchair instructions
- brakes
- foot and armrest
- steering forward and back and right and left
- your free leg is for steering
- your free arm is for driving
- pull the floor toward you (forward, right, left)
- push the floor away (backward)
- pull back on wheel to turn towards uLE (right or left)
things to watch out for
gait deviations
facial expressions
posture deviations
watch for not wanting to extend through weak leg
what is our job?
to facilitate
stabilize where needed (with leg and hand and head)
be the supporting shadow
start proximal, work to distal
know that we won’t fix it all at once
tie it in with motivation -> make it mean something
talk to the patient - tell them what you want them to do.
PT interventions to decrease rigidity
slow gentle rocking
slow rhythmic rotational movements
PT interventions to decrease spasticity
prolonged stretch weight-bearing weight-shifting deep pressure on long tendons rhythmic rotation activation of antagonist muscles slow stroking to paravertebral muscles (calming)
list exercises to improve Static Balance
Romberg standing Staggered standing Tandem standing Single leg stance To progress, perform: - With eyes closed - With head movement - With arm movement - On compliant surface - While doing cognitive task
list exercises to improve Dynamic Balance
Weight shifting Reaching to limits of stability in all directions Stepping all directions Alternate stepping up and down on step Throwing/kicking ball Rocker board, compliant disc, foam External perturbations Multidirectional walking Tandem walking Walking with head turns Carrying objects while walking Walking with 180˚ and 360˚ turns Walking with sudden stops Stepping over objects Braiding Figure eights
