Week 1 Flashcards
Approach to neurorehab 1900
orthopedic approach
corrective exercise and muscle re-education
focus on structural anatomy and principles of exercise
Emphasis placed on regaining function by compensating with unaffected limb
Approach to neuro rehab 1950
Neurofacilitation approach = physiotherapist moving patients through patterns of movement
patient passive recipient
Approach to neuro rehab 1980
Therapeutic approaches of Bobath and Knott and Voss dominated
improved access to scientific literature, physiotherapy postgraduate courses and technology resulted in an increase in clinically relevant research related to movement (biomechanics and neuroscience)
Experimental work focused on how humans acquire skill in movement (motor learning) muscle biology, muscle adaptability and psychology
Carr and Shepherd proposed motor learning approach
Conflicts in clinical practice due to substantial differences in theories and approaches
Evidence based practice increasingly emphasised
Approach to neurorehab 1990
therapeutic approach of Bobath dominated in australia
Hybridisation
-integration of new methods with old at times of major change
-attractive when there is a reluctance to let go of familiar therapeutic methods
-competing theories have philosophical and conceptual differences
Increasing preference for motor learning
- patients active participants in rehab
skill is task specific - task orientated training
goal attainment
approach to neurorehab 2000
Motor learning approaches =skill acquisition
patient active recipient
Approach to neurorehab 2010
Pragmatic eclectic approach = EBP
EBP
select treatment components based on assessment and consideration of the physios skills and expertise
implement evidence based rehab with critical evaluation and awareness of the current evidence that demonstrates that no one approach is superior to any other
EBP cont’
neurorehab using a mix of components from different approaches, is effective for recovery of function and mobility
treatment sessions of 30-60 mins five to seven days a week provide beneficial effect, with more frequent sessions providing added benefit
early intervention is important
no one approach to physical rehab is more or less effective in promoting recovery of function and mobility
EBP cont’ 2
Fundamental principles
- patient centred care
- goal setting
- task specificity
- exercise
Physiotherapy assessment
first, most important step in the rehab
- clinical reasoning will be based and upon which decision is reliant
efficacy of treatment can only be as good as the assessment on which it is based
ongoing and continuous process which leads to the identification of patient problems, setting of patient centred goals and ultimately a tailor made treatment plan for the individual
Holistic assessment
clinical presentation of a patient with neurological deficit is likely to be multifaceted due to the complexity of the nervous system
consideration of the patient as a whole during assessment (and treatment) is imperative to a successful outcome
ICF promotes a framework for a comprehensive assessment of the individual, providing a holistic view of health from biological, individual and social perspectives
PT Ax
evidence of best practice related to assessment protocols is limited
by convention, as per other core physiotherapy areas, neurological assessment is divided into two sections
- subjective assessment
-objective assessment
ICF framework should be utilised as basis to ensure all aspects of the patient are considered
Subjective Examination overview
involves gaining information about the patient and how their condition affects them as a person
personal to a particular patient but may originate from individuals other than the patient (relatives, carer, member of MDT)
May be gathered through various communication methods including medical notes, conversations/meetings and patient interview
in terms of the ICF, the subjective examination gains information relating to activity, participation, environmental and personal factors
Aim and purpose
find out patient’s main problems as perceived by themselves
Assists in development of treatment plan
build rapport with the patient
Information from medical record
personal details
diagnosis
date of admission to hospital: date of admission to rehab unit
History of presenting illness (CVA/SCI/progressive neurological disorder) including specific diagnostic information
CVA: location and type of lesion
SCI : level of lesion, complete/incomplete
TBI: location and type of lesion
Progressive neurological condition: type, progression
info from medical record cont’
relevant PMH - particularly co morbidities that may impact physiotherapy management
Surgical history
results of investigations - x-rays, CT scans, MRI, US/Doppler
Meds
SH
Previous level of function
info from medical record cont’ #2
Medical entries: current interventions and plans
Speech therapy entries: status of swallowing and communication
Occupational therapy entries : result of cognitive and ADL assessment
Nursing entries: bladder and bowel, nursing cares
Info from bed charts
recent observations ( HR, BP, O2 sats, temp) Current meds (especially cardiovascular, sedation and pain management)
Patient interview
History of presenting illness
Any symptom that may affect physiotherapy treatment : chest pain, dyspnoea, dizziness/vertigo
Respiratory : SOB, cough, wheeze, chest pain, secretions
Vision: presence of diplopia or visual field loss
sensation : P&Ns
Strength and power
Coordination and balance
pain : specify shoulder and other part (where, when, how much, what gives relief)
Dominance
Patient interview cont
past or present physiotherapy treatment
SH : family (dependant/support) assistance/services from external agencies (hygiene/meals/community access), accommodation(home environment- stairs, hobs, rails, assistive devices, modifications)
occupation, hobbies/recreation, community mobility(driving, public transport)
Previous level of function. Home and community mobility/level of assistance, aids, exercise tolerance
Falls history : number of falls in last 6/12, causative factors, associated injuries
Patient interview cont 2
patient’s perception of present level of function
patient’s perception of present ability to participate in daily routines
Patient’s perception of major problems
treatment goals
Patient interview cont 3
Take note of
patient’s communication problems and/or strategies
patient’s attitude, motivation and insight into own problems
patient’s cognitive status
you should conduct your initial observations (as per objective assessment) during the patient interview
Objective examination overview
gaining information related to the patient’s movement disorder and functional status using measurable tools and movement analysis
in practical terms, assess how the patient move and then investigate more specifically the reasons for these movement patterns or behaviours
In terms of the ICF, the objective examination gains information relating to: body structures and function and activity
during ongoing treatment, continually re-assess the evaluate change and improvement
Aim and purpose of the objective examination
identify the patient’s movement problems and potential causes of those problems in order to appropriately focus treatment
provide a baseline from which suitable short term and long term goals can be agreed with patient and from which the effectiveness of treatment can be evaluated
Initial observations
level of consciousness general appearance posture or deformities skin condition oedema Quality of spontaneous movement/general movement patterns(weakness, tremor, fascial symmetry and expression speech apparent neglect
initial observations cont
presence of attachments
aids and appliance
gait and or use of wheelchair
respiration - RR, breathing pattern, cough
Attachements (O2, IV, IDC, IV, cardiac monitoring
Vision
visual acuity eye movements - CN III, IV, VI -eye follow - convergence/divergence visual field - hemianopia visual inattention
sensation
light touch double simultaneous stimulation pin prick temperature proprioception - passive movement sense - joint position sense - vibration stereognosis
Flexibility, tone and spasticity
flexibility - PROM Muscle tone - resistance to PROM Spasticity
Quality of active movements
during testing movement and motor recovery always note is there spontaneous movement ? is it isolated? is there any evidence of patterning? if so, describe is the movement antigravity? trunk lower limbs upper limb
Muscle power
standard muscle strength tests can only be recorded if the movement is fully isolated and tone is normal
use standard muscle tests on standard charts
Muscle strength grading scale (oxford scale)
0/5 - no contraction
1/5 visible/palpable contraction, but no movement
2/5 movement with gravity eliminated
3/5 movement against gravity only
4/5 movement against gravity with some resistance
5/5 movement against gravity with full resistance
Co-ordination
should only be assessed when full isolated active movement is present. when testing co-ordination, the following should be noted
speed
smoothness of the movement
presence of dysmetria( undershooting or overshooting)
Timing/Rhythm
Ability to follow a sequence
Co-ordination cont
upper limb
- finger to nose
- pronation /supination
- hand tapping
- finger strumming
lower limb
- foot tapping
- heel/knee/shin
- alternate hip flexion
- alternate hip and knee flexion
- cycling of legs
Functional Task analysis
functional task analysis involves observation of the functional movements and analysis of the components of the movement present/absent
the primary aim is to observe the movement disorder and decide why the movement is abnormal
functional task analysis cont
when assessing functional tasks, analyse the following - level of independence independant supervision verbal cueing minimal assistance x1 moderate assistance x1 minimal assistance x2 moderate assistance x2 unable to perform
movement components
casual factors
Functional task analysis cont 2
Functional task assessment bridging supine to side lying (rolling) side lying to sitting over edge of bed sitting to standing standing to sitting
sitting balance
standing balance
gait
Balance
complete as part of the functional assessment
key tips for safety
-start with easy measures and progress to more difficult ones
-progress from sitting to standing
-progress from static to dynamic
- progress from wide base to narrow base
balance cont’
balanced sitting - static balance - dynamic balance balanced standing - static standing -dynamic standing
Balance cont 2
High level balance and functio - heel to toe walking braiding running skipping hopping star jumps scissor jumps bouncing balls
gait
Complete as part of functional assessment
assess safety of client to walk alone or with assistance
record level of independence and use of aids/orthoses
note effect of footwear
describe general gait characteristics
- speed, step length and cadence
symmetry
arm swing
trunk rotation
test gait over a variety of surfaces (carpet, concrete, grass, sand, ramps, stairs)
Gait cont’
stance phase
Anterior/posterior hip control - hip should extend throughout stance
medial/lateral hip control
knee control - knee should flex from heel strike to mid stance: extend at midstance; flex prior to toe off
Foot contact (heel strike)
Rollover(amount of dorsiflexion occurring at the ankle)
Push off
Gait
Swing phase
hip flexion knee flexion dorsiflexion internal rotation of pelvis knee extension
Other systems
a complete neurological examination requires the assessment off any other systems that may be compromised
neurological disorders are highly associated with both respiratory and circulatory dysfunction and it is of the highest priority that these systems are assessed in acute or progressive conditions
Respiratory
observation
palpation
auscultation
cough/sputum
circulatory
observation (redness, oedema/swelling)
palpation (pain/temperature )
Homan’s Test
Pulses (dorsalius pedis and posterior tibial)
