Treatment Flashcards
what special considerations should be taken when using PROM on neurological patients?
- Subluxation or dislocation of the glenohumeral joint , especially if the patient has low tone
- Speed of PROM - activating muscle spindles and creating tonal changes
- Enviroment/external stimulus.
How does the environment impact high tone?
High tone will increase when-
- Base of support is smaller
- Cold temperatures
- Pain
- Discomfort
- Loud verbal stimulus.
How can you reduce high tone?
- Medication management (Baclofen and Tizanidine)
- Positioning management
- Stretching
- Passive range of movement
- Increasing base of support
How can you activate low tone?
- Strengthening
- Reducing base of support
- Sitting/Standing position to increase alterness
How long would you need to stretch a neurological patient to see elastic changes?
- 30-60 seconds
Why might you apply an elastic stretch?
- Improve ROM
- Improve sensory feedback
- prime the joint/muscle for functional practice and further therapy.
How long would you need to stretch a neurological patient to see plastic changes?
8 hours @ low force with gentle increase stretch into resistance and hold
What is the typical pattern of spasticity in the UL?
- Shoulder med rotation/adduction
- Elbow flexion/pronation
- Wrist/fingers flexed.
How might you apply a plastic stretch and why ?
- Serial Splinting
- To ensure permanent changes to muscle length.
what are the different PNF techniques for stretching?
- Contract-relax
- Reciprocal inhibition
- Contract-relax-agonist contract.
What types of STMs would you use in clinical practice?
- Kneading
- Pick up
- Effleurage
Give an example of when you would use kneading with a neuro patient in clinical practice
to gastrocnemius prior to stretch to prime muscle and give sensory feedback in order to enhance stretching regime for neuro patient with tight gastric/soleus limting plantarflexion.
What does POLICE stand for?
- Protection
- Optimal loading
- Ice
- Compression
- Elevation
What is the concave and convex rule?
If the moving surface is convex , sliding is in the opposite direction of the angular movement of the bone.
If the moving joint is concave , sliding is in the same direction as the angular movement of the bone.
Explain the grading system for maitlands mobilizations
Grade 1- Small amplitude but not into resistance, remains in available range of movement
Grade 2- Large amplitude but not into resistance , remains in available range of movement
Grade 3 - Large amplitude into resistance
Grade 4 - Wall amplitude into resistance
Briefly explain neuroplasticity -
Ability of the brain to recover from injury or disease through a restorative change process through means of
re-growth, repair, restoration and rewiring of neuronal pathways alongside the neuroplastic reorganisation of partially spared pathways.
What affects motor learning?
- Age
- Co-morbidities
- Medications
- Genetics
- Exercise and pre-conditioning
- Prognosis and diagnosis
What are the different stages of motor learning?
- Cognitive
- Associative
- Autonomous
How would you progress trunk stability and trunk mobility in a patient post CVA/TBI
- Sitting balance - both static and dynamic
- Sit out in appropriate chair - increasing time gradually
- Trunk mobilisation and facilitation of pelvic movement in sitting
- Strengthening of the core muscles , reaching , grabbing , as well as throwing a catching.
- Perch sitting
How would you progress trunk stability and mobility in SCI patients?
- Awareness of what level the injury is at
- total or partial paralysis
- Which trunk muscles are innovated
- Ensuring no hinging at injury level
- Correct supported seating.
How do you progress sitting balance?
- Hemiplegia- lean to unaffected and compensate
- Lean affected, limited support , aiding fixing and righting reactions
What is clonus?
Involuntary muscle contractions
What can we do to aid sitting balance? same for TBI/SCI/stroke etc
- 1 person supporting trunk and 1 person supper the pelvis
- Using a gym ball to get a better position
- Using exercise balls to work on dynamic sitting balance
- Range of hand on/hand off treatment where appropriate
- Focusing on alignment/strengthening/quality of movement
What special considerations do we need to make for SCI patients with sitting balance.
- Bilateral weakness
- Providing support for the upper limb
- Using scapula for retraction and protraction
- Using a mirror for sensory feedback , however the mental health of the patient should be considered
- Verbal feedback
- Touch feedback
- Visual feedback - lines for midpoint
- Tactile/visual/verbal cues
- Progression for visual cues and elimination of tactile support.
- Proprioception and balance
Do we transfer patients to both the affected and unaffected side?
Both the affected and unaffected side , aids strengthening and increases independence
Why do we stand patients?
- Increase weight baring
- Increase strength
- Motor recruitment
- Psychological benefits
- Visual stimulation
- Increase bone density
- Decrease risk of secondary MSK complications
- CV benefits
- Respiratory benefits
- Relieves pressure
- Bowel and bladder function
- High centre of gravity/small base of support , meaning balance and postural muscles working
How would you stand an early stroke or traumatic brain injury patient?
- If level of deficit allows attempting standing with support/assistance - blocking the knee and support the affected arm.
How would you stand a Spinal cord injury patient?
SCI patients may need to commence upright stance position with use of tilt table/electric standing frame in order to accommodate for BP changes/regulation - gradual increase to vertical especially for Cx injury due to risk of AD.
What provides stability in the GH joint ?
- Direction of glenoid fossa
- Glenoid labrum
- Capsule - superior
- Rotator cuff muscles
What are the four types of subluxation?
- superior - tight supraspinatus/deltoid
- Inferior
- Anterior
- Posterior
What are the recognised treatment options early post-stroke and TBI?
- Care of the shoulder( education, positioning, supportive device
- Strengthening
- Sensory training
- Mirror box therapy
- Mental practice
- FES
How do you take care of the shoulder in the early stages post stroke?
- Positioning for support
- Potential use of sling during therapy sessions focused on lower limb
- Ensure safe and supportive handling of UL
- Pain management
Name two types of UL splints-
1- Resting leader grip splint
2-Preformed cone/Spasticity splint
Briefly discuss mirror therapy-
- Affected arm behind the mirror
- focus on the reflection and imagines its in the affected limb
- recommended 10 mins a day
- tricking the brain into thinking this reflection is the affected hand and makes it easier to move.
What outcome measures could be used for UL assessment?
- 9 hole peg test
- Fugl-Meyer
- MAS - motor assessment scale
- Action research arm test (ARAT)- Functionality and co-ordination in the upper limb
- Wolf motor function test - Functional tasks of the UL
State the definition of balance-
- The static or dynamic equilibrium of the body, relative to the support base
What do we need for normal balance?
- Intact sensory receptors
- Intact PNS and CNS to transmit , receive and process sensory information
- Intact CNS and PNS to initiate , produce and transmit motor output
- Intact musculoskeletal system
What automatic balance reactions may you observe?
- Ankle strategy
- Hip strategy
- Trunk and head righting reactions
- Protective and saving reactions
- Stepping reactions
What outcome measures would you use for your balance assessment ?
- Rombergs test
- TUSS( timed unsupported steady stand)
- FR - functional reach
- 180 TURN
- POMA
- BBS ( Berg Balance Scale)
- GUAG( Get up and go)
- Star excursion test
- Y balance test
What can you do in clinical practice to challenge balance?
- take away sense
- reduce the base of support
- Raise the centre of gravity
- encourage automatic reactions
- Add reactive or proactive elements
- Add dual tasking
What is the rationale for using a walking aid short term?
- to enable mobility and facilitated increased independence , social interaction , weight baring and return function
What is the rationale for using a walking aid long term?
- to reduce risks of falls, to enable continued mobility and independence , for fatigue management.
What considerations should be made when issuing walking aids?
- Compensations
- Reliance
- Changes in gait cycle
- Cognition
- Falls risk
How do you measure for a stick or elbow crutch?
- ulnar styloid
What stick would you prescribe for a patient with an arthritic hand?
Fischer stick
What are some reasons for limited upper limb recovering following CVA/TBI
- Depression/anxiety
- Cognition
- Severity of paresis
- Poor sensation/limiting sensory recovery
- Visual inattention
- Flaccidity and spasticity
Contraindication to using electrical stimulation
- Cognition
- Pregnancy
- Over eyes
- Epiphyseal regions in children
- Pacemakers
- Skin allergies
- Dermatological conditions
- Tumour or suspected malignancy
What are the main areas in which FES ( Functional electrical stimulation) is used?
- Correction of foot drop in MS and CVA
- Reduction in hemiplegic shoulder pain
What is CIMT?
Constraint induced movement therapy
How and why is CIMT affective?
To encourage use of affected arm, to give increased sensory stimulation to affected arm , to stop compensations in affected arm , with a glove.
How long is the non-affected limb recommended to be constrained in CIMT
90% of all waking hours
What do you always need to consider when mobilising a Neuro Patient?
- BP
-Heart rate
-Respiratory Rate
-02 saturations
-Consciousness
What do you need to consider when mobilising a SCI patient?
- impairment in vasomotor control- BP,HR,RR
- Postural hypotension
- Autonomic dysreflexia
-Problems with bladder and bowel function
-Unstable spine - Abdominal binder to maintain abdominal pressures
Observation of the Trunk
Symmetry/muscle activity
Weight-bearing
Level of pelvis
Skin creases
Levels of Scapulae
Levels of shoulders
Arm position
Head position
What to observe for Trunk Stability AROM
- Ant/Post pelvic tilt with flex/ext of trunk
-Lateral pelvic tilt with side flex of trunk
-Combination
-With arm reaching
-Righting reactions- Head and Trunk
What to consider when carrying out passive ROM on a Neuro patient?
- Where you put your hands
- Speed
-Range
-Support
-Resistance
What is ataxia?
Ataxia describes poor muscle control that causes clumsy voluntary movements. It may cause difficulty with walking and balance, hand coordination, speech and swallowing, and eye movements. Ataxia usually results from damage to the part of the brain that controls muscle coordination (cerebellum) or its connections.
What would you observed in sitting/gait ( Ataxia)?
OBSERVATION. Posture: widened base of support, may be trunk flexed and hands apart to maintain balance. Gait: ataxic gait, High stepping gait, feet slapping gait. Involuntary movement: Tremor. Location(distal limb/truncal/head)
Outcome measures for Trunk
- Postural Assessment scale for stroke( PASS)
- Trunk impairment scale
-Melsbroek Disability Scoring Test (MDST)
