Week 5: Assessment of Motor Control Flashcards
What is part of proximal motor control?
trunk, scapular, shoulder, elbow tone , ROM, motor control, strength
Ability to make dynamic postural adjustments and direct body and limb movement in purposeful activity
Motor Control
What components necessary for motor control?
normal muscle tone, normal postural tone and postural mechanisms, selective movement, coordination
Functional recovery depends on 5 things…
- initial amount of neurologic damage
- prompt access to medical treatment that limits extent of neurologic damage
- nature of neurologic damage
- whether it is static or progressive
- therapeutic intervention that can facilitate motor recovery
anatomical and electorphysiological changes in the CNS
neuroplasticity
T/F: some instances CNS is able to recognize and adapt to functional demands after injury
True
What are 2 ways motor relearning can occur?
- existing neural pathways (unmasking)
development of new neural connections (sprouting)
seldom used pathways become more active after primary pathway has been injured, adjacent nerves take over functions of damaged nerves
unmasking
dendrites from one nerve form a new attachment or synapse with another, new axonal processes develop in sprouting
sprouting
What’s a way to assess motor control?
observation of movement during OP
What are specific components of motor control?
- muscle tone
- postural tone
- postural mechanism
- reflexes
- selective movement
- coordination
this includes any nerve cell body or nerve fiber in spinal cord (other than anterior horn cells) and all superior structures like descending nerve tracts and brain cells of gray and white matter
upper motor neuron system
this includes anterior horn cells of spinal cord, spinal nerves, nuclei and axons of cranial nerves III and X, and peripheral nerves
lower motor neuron system
what does LMN dysfunction result in?
diminished or absent deep tendon reflexes and muscle flaccidity
Tool helps prioritize lint’s functional activity goals in areas of self care, leisure, productivity
COPM
What to consider when observing client for motor control?
- during ADL, IADL
- problems affecting motor control
- consider client’s sensation, perception, cognition, medical status
Test helps OT distinguish between normal and pathological aging in upper extremity performance - include picking up and moving jar, writing on envelope, tying scarf, handling coins
TEMPA
T/F: UMN facilitates/inhibits LMN
true.
What kind of assessments designed for motor control problems?
- Graded Wolf Motor Function Test
- Wolf Motor Function Test
- Functional Test for Hemiplegic Upper Extremity
- Fugl-Meyer
- Arm Motor Ability Test
- Motricity Index
- Assessment of Motor and Process Skills
Measure functional gains after hemiparetic event from CVA or TBI. 2 levels of difficulty for each task.
Level A is advanced, Level B is easier.
Graded Wolf Motor Function Test
Test used to quantify motor abilities of chronic clients from population with high UE function following CVA or TBI. Reliable 95097%
Wolf Motor Function Test
Test assesses client’s ability to use involved arm for purposeful tasks. Provides objective documentation of functional improvement and includes task ranging from those involve basic stabilization to more difficult tasks. ex) holding pouch, stabilizing jar, hooking zipper, folding sheet, putting light bulb
Functional Test for Hemiplegic Upper Extremity
Test based on natural progression of neurotic recovery after CVA. Low scores correlated with presence of severe spasticity. Measures paraments as ROM, pain, sensation, balance. Scores correlate with ADL performance
Fugl-Meyer
functional assessment of upper extremity function. Cutting meat, making sandwich, opening jar, putting on T shirt. Has high interrupter and test retest reliability
Arm Motor Ability Test
Perform quickly, it assess pinching cube with index finger and thumb, as well as elbow flexion, shoulder abduction, ankle dorsiflexion, knee extension, and hip flexion
Motricity Index
standardized test assesses motor and process skills in IADLs. Test created by OT. Eligible after 5 day training course.
Assessment of Motor and Process Skills
What does OT do after observing functional performance?
Assess performance components that underlie motor control: muscle tone (normal/abnormal), postural mechanism, muscle tone assessment/reflex, sensation, coordination.
Continuous state of mild contraction, or state of preparedness in muscle
Normal Muscle tone
Resistance felt by examiner as he or she passively moves client’s limb
tone
When is normal muscle tone present?
When tension between origin and insertion of muscle is felt as resistance by OT when passively manipulating limn. It is high enough to resist gravity but low enough to allow movement
Normal muscle tone relies on normal function of…
cerebellum, motor cortex, basal ganglia, midbrain, vestibular system, spinal cord, neuromuscular system, stretch reflex
- effective coactivation/stabilization at axial and proximal joints
- ability to move against gravity and resistance
- ability to maintain position of limb if it is placed passively by examiner and then released
- balanced tone between agonist and antagonistic muscles
- ease of ability to shift from stability to mobility and to reverse if needed
- ability to use muscles in groups or selectively with normal timing and coordination
- resilience or slight resistance in response to passive movement
Characteristics of normal tone
What is desirable when striving for selective motor control?
normalization of muscle tone and amelioration of paresis
flaccidity, hypotonus, hypertonus, spasticity, rigidity
other terms for abnormal muscle tone
Absence of tone. Can result from spinal or cerebral shock after spinal or cerebral insult. Result from LMN dysfunction
Flaccidity
Decrease in normal muscle tone. Deep tendon reflexes are deminished or absent
Hypotonus
Increased muscle tone
Hypertonus
Caused by TMI, stroke, anoxia, neoplasms, metabolic disorders, CP, disease of brain. Tone fluctuates
Cerebral Hypertonia
Results from diseases and injuries of the SC. In slow onset spinal disease, there is no shock. In traumatic SCI, shock occurs and there is initial flaccidity. This diminishes and then hypertonus develops.
Spinal Hypetonia
motor disorder characterized by velocity-depedent increase in tonic stretch reflexes with exaggerated tendon jerks resulting from hyperexcitaility of stretch reflex as one component of UMN syndrome
spasticity
CVA, brain injury, MS, Parkinson’s are common when …
motor control is lacking
What does recovery depend on?
Recovery depends on initial amount of damage, prompt access to medical treatment that limits the extent of neurologic damage, the nature of neurologic damage, whether it is static or progressive, and therapeutic intervention that can facilitate motor recovery
What does The upper motor neuron system consist of?
includes any nerve cell body or nerve fiber in the spinal cord (other than anterior horn cells) and all superior structures.
T/F: Descending nerve tracts and brain cells of both gray and white matter that subserve motor functions
True
The lower motor neuron system includes…
the anterior horn cells of the spinal cord, the spinal nerves, the nuclei and axons of cranial nerves III through X and the peripheral nerves
BLANK is an upper extremity functional activity performance test for clients
TEMPA
- Helps to distinguish between normal and pathological aging in upper extremity performance
o Picking up and moving a jar, writing on an envelope, tying a scarf, and handling coins, etc.
A continuous state of mild contraction, or a state of preparedness in the muscle.
Normal Muscle Tone
is mediated by the muscle spindle, a sophisticated sensory receptor that continuously reports sensory information from muscles to CNS
Stretch Reflex
o Effective coactivation at axial and proximal joints
o Ability to move against gravity and resistance
o Ability to maintain the position of the limb if it is placed passively by the examiner and then released
o Balanced tone between agonistic and antagonistic muscles
o Ease of the ability to shift from stability and to reverse as needed
o Ability to use muscles in groups of selectively with normal timing and coordination
o Resilience of slight resistance in response to passive movement
Normal Muscle Tone
T/F: Flexing synergy is more common in UE and extension synergy is more common in LE
True
T/F: Clients with UMN lesions will have dysfunction in spatial and temporal timing of movement leading to uncoordinated movements
true
Pressure sores, ingrown toenails, tight elastic straps on a urine collection leg bag, tight clothing, an obstructed catheter, urinary tract infection, constipation and fecal impaction
•Other factors: fear, anxiety, temperature extremes, heterotopic ossification, and sensory overload.
Hypertonus extrinsic factors?
can lead to muscle spasms severe enough to cause someone to fall out of
a bed or a wheelchair. Tone tends to be more severe in incomplete SC lesions than in complete lesions
spinal hypertonia
hyperactivity of muscle spindle’s phasic stretch reflex, velocity dependence, and the “clasp knife” phenomenon whereby when an examiner takes the extremity through a quick passive stretch then a catch or resistance is felt followed by a release
3 characteristics of spasticity
consists of corticospinal and corticobulbar tracts. Is one of the main systems affected when spasticity is present. Voluntary movement.
pyramidal system
T/F: hypertonia is velocity dependent and there is no clasp knife phenomenon
false. hypertonia is not velocity dependent and there is no clasp knife
phenomenon
specific type of spasticity, characterized by repetitive contractions in antagonistic
muscles in response to rapid stretch. Most commonly seen in ankle plantar flexors and finger
flexors.
Clonus
T/F; Therapists should teach clients to bear weight properly as this can usually stop the clonus. Clonus is recorded by number of beats. 3 count clonus is mild, if greater than 10 likely to interfere with ADLs
True
Simultaneous increase in muscle tone of agonist and antagonist muscles. They contract steadily, leading to increased resistance to passive ROM
Rigidity
Occurs in Parkinson’s, TBIs, some degenerative diseases, encephalitis, and tumors,
Rigidity
T/F: rigidity is velocity dependent
False. Rigidity is not velocity dependent
4 types of rigidity…
lead pipe rigidity,
cogwheel rigidity, decorticate rigidity, and decerebrate rigidity
can occur in Parkinson’s.
Lead pipe and cogwheel rigidity
constant resistance is felt through the passive ROM.
lead pipe
is characterized by a rhythmic give in resistance throughout the ROM.
cogwheel
…rigidity can occur after severe TBI. They can last a few days or weeks if recovery, but if no recovery then can last indefinitely
Decerebrate and decorticate rigidity can occur after severe TBI. They can last a few days or weeks if recovery, but if no recovery then can last indefinitely
…rigidity results from lesions in bilateral hemispheres of diencephalon and midbrain. It appears as rigid extension of all limbs and the neck.
Decerebrate rigidity results from lesions in bilateral hemispheres of diencephalon and midbrain. It appears as rigid extension of all limbs and the neck.
….rigidity results from bilateral cortical lesions, appears as flexion hypertonus in UE
and extension in tone in LE.
Decorticate rigidity results from bilateral cortical lesions, appears as flexion hypertonus in UE
and extension in tone in LE.
T/F: Supine positioning increases abnormal tone, so with decerebrate and decorticate rigidity it
is important to be aware that sitting may be difficult
True
Objective assessment is difficult because tone fluctuates in response to extrinsic and intrinsic factors. Position of body and head in space and postural reflex mechanism can all impact degree and distribution of abnormal muscle tone
Muscle tone assessment
Guidelines for muscle tone assessment…
a. Rate spasticity and hypertonia with client in the same position preferably at the same time of day
b. UE muscle tone usually assessed with client sitting on mat table
c. Remember that client’s trunk posture will affect results
d. Tone fluctuates throughout day, making rating difficult especially for cerebral hypertonia.
What is process of muscle tone assessment?
Process: 1. Grasp client’s limb proximal and distal to the joint to be tested and move joint
slowly through its range to determine free and easy ROM available. *Note presence and location of pain. If no active movement and limb feels heavy, report that it is flaccid.
f. If limb has some active ROM and no increased tone, then limb may be labeled “paretic” instead of “hypotonic”, at which point the limb will be graded in strength (1-5 scale with +/-).
Strength grading is important because it is more specific and can be informative for
treatment decisions.
g. Hold limb on lateral aspects to avoid giving tactile stimulation.
h. Clinical assessment of spasticity involves holding limb and moving it quickly. Lable tone as
mild, moderate, or severe.
i. Clinical assessment of rigidity involves moving limb slowly during range, and noting location of first tone in degrees and labeling it mild, moderate, or severe.
j. Important to note posture!!!
….are the two most widely used scales to manually rate spasticity. They were not designed to designate between spasticity and hypertonic stretch reflexes. Used to distinguish the amount of hypertonus.
Some controversy in that the last stage of each scale is describing rigidity, not spasticity. Rigidity is extrapyramidal and spasticity is pyramidal, thus they should not be measured on same
scale.
Ashworth Scale: The Ashworth Scale and the Modified Ashworth Scale
0=Normal muscle tone
1=slight increase in muscle tone, catch when limb is moved
2=More marked increase in muscle tone, but limb easily flexed
3=Considerable increase in muscle tone
4=Limb rigid in flexion or extension
Ashworth Scale
slight increase in muscle tone, catch when limb is moved
1
Limb rigid in flexion or extension
4
Considerable increase in muscle tone
3
Normal muscle tone
0
More marked increase in muscle tone, but limb easily flexed
2
Both Tardieu Scale and Modified Tardieu Scale measure spasticity
Tardieu Scale
mild=stretch reflex occurs at the muscle’s end range.
Mild-Moderate-Severe Spasticity Scale
stretch reflex occurs in midrange. Severe: stretch reflex occurs when the muscle is in a shortened range.
Moderate
0=no abnormal tone is detected during slow, passive
movement. 1 or mild=first tone or resistance felt when muscle in a lengthened position during
slow, passive movement. 2 or moderate=first tone or resistance is felt in the midrange of the
muscle during slow, passive movement. 3 or severe: first tone or resistance occurs when the
muscle is in a shortened range during slow, passive movement.
Preston’s Hypertonicity Scale
T/F: Mechanically determined parameters may be more reliable than manual methods.
True
T/F: Passive ROM assessment supplements and often correlate with tone assessment.
True. xample
is if client has limited ROM of wrist and orthopedic causes are ruled out, then tone should be
assessed in wrist flexors.
b. Assessment of PROM can reveal joint changes, like subluxation, contracture
T/F: Manual muscle testing is usually appropriate for clients with moderate to severe hypertonicity or rigidity
False. Manual muscle testing is usually not appropriate for clients with moderate to severe hypertonicity or rigidity because relative tone and strength of muscles are abnormal.
If hypertonia is mild and selective movement is possible, then can measure.
What can influence
muscle tone and motor control?
Position change, spinal reflexes, reticular formation, and supraspinal reflexes influence muscle tone and motor control.
T/F: Along with assessment of muscle tone, OT also performs test of UE movement and control.
Therapist identifies where and how much client’s motor control is dominated by synergies
and where selective, isolated movement is present. Also identify direction of movement that
causes hypertonicity and how that impacts function.
True
Recommended tests for clients with damage to CNS?
static two-point discrimination, kinesthesia, proprioception, pain, and light touch using Semmes-Weinstein monofilament test
Who should be referred to referred for EMG assessment?
Clients who have flaccidity, numbness, unexplained paresis, or local muscle wasting
omposed of automatic movements that provide stability and mobility. They develop early in life and allow for trunk control, head control, midline orientation, weight bearing and shifting, dynamic balance, and controlled voluntary limb movement
Normal Postural Mechanism
TF: Normal postural tone allows automatic and continuous postural adjustment. Knowing
automatic reactions is important when assessing.
True
Without__________ , client will have difficulty getting up from the floor, getting out of bed, sitting up, and kneeling
Without effective righting reactions, client will have difficulty getting up from the floor, getting out of bed, sitting up, and kneeling
Without _____ , client will have difficulty maintaining and recovering balance
Without equilibrium reactions, client will have difficulty maintaining and recovering balance
If equilibrium reactions cannot correct a deviation in balance, then _____ reactions come into play.
If equilibrium reactions cannot correct a deviation in balance, then protective reactions come into play. They consist of protective extension of arms and hand.
Assessment of righting, equilibrium, protective reactions, and balance?
a. Formal testing may be difficult due to time constraints and physical limitations. They can be evaluated during transfers and ADLs, such as patient shifting farther out of midline
than necessary during LE dressing
b. Balance depends on normal equilibrium and protective reactions
c. When assessing a client with CNS dysfunction, the therapist should assess static and dynamic
balance before leaving the client unattended on a mat table or wheelchair
d. Physical performance Test assesses physical function during activity and takes 10 minutes
to complete
Asymmetric Tonic Neck Reflex is a brainstem level reflex. It is tested with the client positioned supine or sitting.
ATNR stimulus: actively or passively turn client’s head 90 degrees to one side. Response is
increase in extensor tone of limb on face side and increase of flexor tone on skull side of limb.
Client with _____ may have difficulty maintaining head in midline while moving eyes towards or past midline
Client with ATNR may have difficulty maintaining head in midline while moving eyes towards or past midline. Client may be unable to extend arm without turning head, or flex arm without turning head the other way.
____ makes it difficult to bring an object to the mouth, hold an object in both hands, or grasp an object in the front of the body while looking at it
ATNR makes it difficult to bring an object to the mouth, hold an object in both hands, or grasp an object in the front of the body while looking at it
Testing with patient sitting or quadruped
Stimulus: flex client’s head and bring his/her chin towards chest
Response: flexion of the upper extremities (UEs) and extension of the lower extremities (LEs)
Stimulus: extend client’s head
Response: extension of the UEs and flexion of the Les
Symmetric Tonic Neck Reflex (STNR)
If client has this reflex will be unable to support the body weight on hands and knees, to maintain balance in a quadrupod position, or to crawl normally w/o fixating the head. Difficulty moving from lying to sitting, with transfers from bed to wheelchair and from wheelchair to bed
Symmetric Tonic Neck Reflex (STNR)
Testing
Stimulus: client supine with head in midposition
Response: increase in extension tone or extension of the extremities
Can also be tested in prone w/ head in midposition; response is increase in flexor tone or flexion of the extremities
Tonic Labyrinthine Reflex (TLR)
Inability to lift head in supine position
To initiate flexion to sit up independently from supine (will use extensor tone until halfway up when flexor tone takes over causing head and spine to flex making client fall forward)
To roll over
To sit in a wheelchair for long periods (leads to increased extensor tone as client hyperextends head to view the environment, knee is extended pushing foot forward off footrest and may cause client to slip)
Tonic Labyrinthine Reflex (TLR)
Stimulus: pressure on the ball of the foot
Response: rigid extension of the LEs due to co-contraction of the flexors and extensors of the knee and hip joints; can also see internal rotation of the hip, ankle plantar flexion, and foot inversion
Positive Supporting Reaction
Will have difficulty placing heel on the ground for standing, putting heel down first in walking, having normal body weight transference in walking, getting up from chair, sitting in chair, walking down steps
Leg remains in rigid extension and unable to contribute to any balance reactions so balance reactions must be compensated for by other parts of the body
Positive Supporting Reaction
Can occur after an upper motor lesion
Appear b/c lack of integration w/ higher centers
Ex. Hyperactive deep tendon reflex, Babinski sign, flexor withdrawal reflex, crossed extension, grasp reflex
Spinal Level Reflexes
Causes increased extensor tone in one leg when other leg is flexed
Can interfere with normal pattern of ambulation
Crossed Extension Reflex
Flexion of the ankle, knee, and hip when the sole of the foot is touched (swiped heel to ball of foot)
Interferes with gait pattern and transfers
Flexor Withdrawal
Client not able to release objects placed in the hand even if active finger extension is present
Grasp Reflex
4 timed tests: 1) rolling to weak side 2) rolling to sound side 3) moving from supine to sitting 4) sitting on the side of the bed w/ feet off the floor for 30 seconds
Collin and Wade test of trunk control (reliable/valid in clients with CVA)
To assess trunk control therapist must evaluate strength and control in following:
To assess trunk control therapist must evaluate strength and control in following: trunk flexors, extensors, lateral flexors, and rotators
Client sitting upright on mat table w/ feet supported; shouldn’t be left unattended unless determined safe
Test trunk flexors..
Ask client to sit upright and slowly move shoulders behind the hips (eccentric control) and to hold the end-rage posture (isometric control)
Then asked to move forward (concentric control) to resume the initial upright posture
Look for unilateral weakness, potential for falls, and symmetry of weight shift
Functional test: observe client move from supine to sitting
Test trunk extensors…
Test 1
Client sits in position of spinal flexion with posterior pelvic tilt and moves into trunk extension while moving pelvis into neutral or slight anterior tilt (assesses concentric trunk extensor control needed for LE dressing and forward reach)
Look for signs of unilateral weakness and note end-range control
Test 2
Client seated upright and asked to maintain erect spine and lean forward (eccentric trunk extensor control)
Look for signs of unilateral weakness and note end-range control
Test 3
Client asked to move shoulders back to assume a seated, aligned, upright position (extensors contracting concentrically)
Client sits in upright posture, pelvis stationary and upper trunk laterally flexes toward mat table (eccentric) and asked to return to original (concentric)
When movement initiated from lower trunk and pelvis end position is one of trunk elongation on the weight-bearing side and shortening on the non-weight bearing side
Lateral flexion needed for fall prevention when reaching to the side
test lateral flexors
Primary muscles responsible are obliques
Rotate trunk to left the right external and left internal obliques are recruited
Test trunk rotation
Three movement patterns evaluated for trunk rotation…
Client sits upright pelvis in neutral; reaches w/ right arm across body in direction of the floor (assess concurrent flexion and rotation and concentric control of the obliques and back extensors) both sides tested
Trunk extension w/ trunk rotation; upper trunk stable while lower trunk and pelvis move forward on one side (shifting forward) both sides tested
Positioned in supine; client initiates segmental roll by lifting shoulder from surface and toward opposite side of the body (concentric contraction of the obliques)
Smoothness, rhythm, appropriate speed, refinement to the minimum number of muscle groups needed, appropriate muscle tension, postural tone, and equilibrium
Under control of the cerebellum and influenced by extrapyramidal system
For coordinated movement all elements of neuromuscular mechanism must be intact and proprioception AND body scheme, ability to judge space accurately, and direct body parts through space w/ correct timing to desired target
Depends on contraction of correct agonist muscles w/ simultaneous relaxation of correct antagonist muscles w/ contraction of joint fixator and synergist muscles
Coordination: ability to produce accurate, controlled movement
Signs of cerebellar dysfunction
Ataxia Adiadochokinesis Dysmetria Dyssynergia (decomposition of movement) Rebound Phenomenon of Holmes Nystagmus Dysarthria
Delayed initiation of movement responses, errors in range and force of movement, and errors in rate and regularity of movement
Poor coordination between agonist and antagonist muscle groups → jerky, poorly controlled movements
Staggering, wide-based gait with reduced/no arm swing, step length may be uneven, may have tendency to fall
If dysfunction to one hemisphere tendency to fall on side of lesion
Poor postural stability
Ataxia
Inability to perform rapid alternating movements such as pronation/supination or elbow flexion/extension
Count how many cycles client perform in 10 seconds (1 = one full repetition of supination/pronation)
Best to test unaffected first and then compare
Adiadochokinesis
Inability to estimate ROM necessary to reach the target of movement
2 types: hypermetria is limb overshooting the target; hypometria is limb undershooting the target
Dysmetria
Voluntary movements broken up into their component parts and appear jerky
Can cause problems in articulation and phonation
Dyssynergia (decomposition of movement)
Lack of check reflex, inability to stop motion quickly to avoid stroking something
Rebound Phenomenon of Holmes
Explosive or slurred speech caused by incoordination of speech mechanism
Speech may vary in pitch or seem nasal and tremulous or both
Dysarthria
Characterized by hypokinesia or hyperkinesia Ex. Parkinson’s is hypokinesia Parkinson’s plus name given to group of movement disorders that have signs of parkinson’s disease w/ concomitant neurologic deficits Chorea Athetoid movements dystonia ballism tremor
Extrapyramidal Disorders
Irregular, purposeless, involuntary, coarse, quick, jerky, and dysrhythmic movements of variable distribution that can occur during sleep
Huntington’s disease and tardive dyskinesia often present with chorea
Choreiform movements are faster than athetoid movements
Chorea
Continuous, slow, wormlike arrhythmic movements that primarily affect the distal portions of the extremities
Not present during sleep; occur in same patterns in the same individual
Movement patterns including alternating flexion/extension of arm, supination/pronation of forearm, flexion/extension of fingers
Choreoathetosis: athetosis that occurs with chorea
Athetoid Movements
Persistent posturing of the extremities (Ex. In hyperextension or hyperflexion of the wrist, fingers) often w/ concurrent torsion of the spine and associated twisting of the trunk
Movements are often continuous and seen in conjunction w/ spasticity
Can be primary or secondary (can occur w/ other CNS disorders)
Segmental dystonia involves 2 or more adjacent body parets
Focal dystonia: involves only 1 limb
Generalized and multifocal types of dystonia also exist
Dystonia
Rare symptom produced by continuous abrupt contractions of the axial and proximal musculature of the extremity
Causes the limb to fly out suddently
Occurs on one side of the body (hemiballism) and caused by lesions of the opposite subthalamic nucleus
Ballism
Associated w/ cerebellar disease and occurs during voluntary movement; intensified at termination of movement; often seen in MS; difficulty w/ accuracy/precision
Intention tremor: associated w/ cerebellar disease and occurs during voluntary movement; intensified at termination of movement; often seen in MS; difficulty w/ accuracy/precision
at rest and subsides when voluntary movement attempted; occurs as result of damage of disease of the basal ganglia and seen in Parkinson’s
Resting tremor: at rest and subsides when voluntary movement attempted; occurs as result of damage of disease of the basal ganglia and seen in Parkinson’s
inherited as autosomal dominant trait; most visible when client is carrying out a fine, precision task
Essential familial tremor: inherited as autosomal dominant trait; most visible when client is carrying out a fine, precision task
General guidelines and questions when evaluating incoordination
Assess muscle tone and joint mobility first in sitting
Observe for ataxia (proximal to distal) during functional UE movement
Stabilize joints proximally to distally during functional task and note differences in client performance as compared w/ performance w/o stabilization
Can stabilize by splinting or stabilizing against wall
Can use weighted cuffs to determine if weighting or resistance decreases/increases tremor or makes coordination worse
Observe for tremors
Are eyes and speech affected?
Does client’s emotional status affect coordination?
How does their ataxia/coordination probs affect participation in occupation?
Perform OP and performance patterns interview to determine client’s roles, routines, goals, and environment to determine what functions are important
account for ~80% of all strokes; caused by a blockage of a blood vessel supplying the brain.
Ischemic Strokes – account for ~80% of all strokes; caused by a blockage of a blood vessel supplying the brain.
result from the rupturing of an artery, causing blood to leak into the brain.
Hemorrhagic strokes – result from the rupturing of an artery, causing blood to leak into the brain.
was the nation’s 4th leading cause of death.
stroke
The course of recovery after stroke is predictable.
The course of recovery after stroke remains unpredictable since some individuals regain full function & others regain very little.
The location, size, and type of the brain lesion affect the prognosis for recovery, but most people report decreased levels of activity, social interaction, and overall life satisfaction poststroke.
Sudden numbness/weakness of the face, arm, or leg (esp. on one side of the body).
Sudden confusion or trouble speaking or understanding.
Sudden difficulty seeing in one or both eyes.
Sudden dizziness, trouble walking, or loss of balance or coordination.
Sudden severe headache with unknown cause.
Warning Signs of Stroke
Hemiplegia/hemiparesis: decreased fxn on one side of the body.
Apraxia: motor planning problems.
Dysphagia: difficulty swallowing.
Dysarthria: oral motor difficulties characterized by poor articulation.
Aphasia: receptive and/or expressive language & communication deficits.
Cognitive deficits (e.g. impulsivity, decreased insight & judgment, memory loss)
Visual-perceptual deficits (e.g. homonymous hemianopsia, unilateral neglect)
Somatosensory deficits: impairment of sensation.
Psychosocial deficits (e.g. depression, denial, anger, emotional lability)
Effects of Stroke
Medical status/stability – assess daily before intervention during acute stage of recovery.
Cardiac & respiratory precautions – monitor for dizziness, breathing difficulties, chest pain, excessive fatigue, and altered heart rate or rhythm.
Fall prevention – provide supervision & assistance during all transfers.
Shoulder injury or pain – never move an individual by the affected upper extremity.
Skin integrity – monitor frequently.
Swallowing status – refer to speech-language pathologist as needed to determine swallowing ability.
Poor safety awareness & impulsive behavior – provide appropriate level of supervision.
Contractures – when appropriate, follow individualized preventative program of proper positioning, soft tissue & joint mobilization, and ROM exercises.
General safety concerns – educate the individual, family, and other healthcare providers regarding all precautions to maximize safety.
precautions for stroke
Alcohol & tobacco use, physical inactivity, high bp & cholesterol, heart disease, diabetes, sickle cell anemia, obesity, previous stroke, family history of stroke, and aging.
Risk Factors for stroke
Healthy diet, maintaining a healthy weight, remaining physically active, avoiding tobacco use, limiting alcohol use, and managing/treating other medical conditions.
prevention stroke
measures type & amount of assistance needed for safe and effective activity performance.
Functional Independence Measure (FIM) , eval for stroke
American Heart Association Stroke OUtcome Classification – evaluates extent & severity of impairment & level of functional independence.
Functional Independence Measure (FIM) – measures type & amount of assistance needed for safe and effective activity performance.
National Institute of Health Stroke Scale (NIHSS) – assesses level of impairment
Chedoke-McMaster Stroke Assessment – assesses physical impairment & fxnl ability
evals for stroke
Assessment of Motor and Process Skills (AMPS) – observational assessment
Barthel Index (BI) – assesses self-care abilities & level of assistance needed
Activity Card Sort (ACS) – clients describe their instrumental, social, and leisure activities
Frenchay Activities Index (FAI) – measure of ADL & IADL participation
ADL stroke assessments
Fugl-Meyer Assessment of Motor Function
Functional Test for the Hemiplegic/Paretic Upper Extremity
Modified Ashworth Scale (MAS) – measure of muscle spasticity
Goniometry – measures ROM
Manual muscle testing, dynamometer, and pinch meter – assess strength
Volumeter – measures edema
Upper Extremity Function Evaluations
Berg Balance Scale (BBS)
Postural Assessment Scale for Stroke Patients (PASS)
Motor Assessment Scale (MAS)
Balance Evals
Behavioral Inattention Test (BIT)
Rivermead Behavioral Memory Test (RBMT)
Executive Function Performance Test (EFPT)
Loewenstein Occupational Therapy Cognitive Assessment (LOTCA) – assesses orientation, visual & spatial perception, visuomotor organization & thinking operations.
Catherine Bergego Scale – behavioral assessment of unilateral neglect.
Cognitive/Perception Eval
COPM – self-report of performance & satisfaction w/ occupations.
Short-Form 36 Health Survey (SF-36) – evaluates health-related quality of life.
Stroke Impact Scale (SIS) – self-report health status measure.
Stroke-Specific Quality of LIfe Scale (SS-QOL) – self-report questionnaire.
Quality of life eval
Neuromuscular Musculoskeletal Cognitive/perceptual/sensory Physical agent modalities/orthotics/splinting Skills acquisition/task-specific training Adaptive/compensatory Educational Psychosocial
Occupational Therapy Interventions
Research findings also indicate that effective practices to improve upper limb motor recovery after stroke include…
Research findings also indicate that effective practices to improve upper limb motor recovery after stroke include a combination of mental & physical practice & the use of extrinsic feedback to enhance motor learning.
Current evidence supports task-specific, task-oriented, and/or repetitive task practice.
