WK5-6 - Brain Impairment and PA Flashcards
What is the role of the parietal lobe?
Processes/interprets sensory info: perception, spatial awareness, manipulating objects and spelling
What is the role of the occipital lobe?
vision reception, processing and intepretation
What is the role of the cerebellum?
coordination of smooth voluntry movement
Maintains balance/equilibrium
Some memory for reflex motor activity
What is the role of the frontal lobe?
- planning/organising
- attention
- problem solving
- emotional and behaviour control
- social skills
- skilled motor performance
- expressing language (Broca’s area)
What is the role of the temporal lobe?
- hearing
- memory acquisition
- understanding language (Wernicke’s area)
- visual perception (recognition&categorising objects)
What is the role of the brain stem (pons, midbrain and medulla)?
- breathing
- HR
- swallowing
- reflex responses to visual/auditory input
- level of alertness
- regulating sleep/wake cycle
Expain the general organisation of motor control. Why is it important?
3 levels of control: SC, brain steam and forebrain
- organised both serially and parallel
- motor areas of cerebral cortex influence SC directly or indirectly through descending systems of brain stem
- all motor systems receive sensory inputs and under influence of 2 independent subcortical systems: basal ganglia and cerebellum
Ganglia & cerebellum act on cerebral cortex through relay nuclei in thalamus.
what are the 3 broad causes of BI?
- Dysgenesis - abnormal organ development during embryonic development (in womb) / disordered development of malformation
- trauma/injury - TBI
- disease / infection - may lead to a stroke, MS or parkinson’s
What is the aetiology / common features between CP and TBI?
- non-progressive
- can affect physical, cognitive and behavioural functioning (proportions different)
- in relation to Ex and PA for post-acute clients, there are common areas: benefits, Ax, prescription/programming, methods of promotion
Ex effects are treated collectively under BI in EXMD3070
What is CP?
Cerebral = brain
Palsy = paralysis
- umbrella term covering group of non-progressive (but changing) disorders of movements or posture 2ndary to lesion or abnormality in motor areas of developing brain
Lesion may occur (all overlap):
* antenatally - anytime prior to birth
* perinatally - during/immediately after birth (20-28wks) (4wks post birth is perinatal area
* postnatally - anytime after work
When does CP occur (%), provide timeline and aetiology?
Antenatal: ~80%
- Conception to pregnancy
- abnormal chromosomal, cerebral dysgenesis, fetal hypoxia ischaemia, foetal infection
Perinatal: ~6-10%
- labour/4wks after birth
- intrapartum hypoxia-ischaemia
Postnatal: ~15%
- neonatal complications
- postneonatal trauma or infection
What are the CP risk factors?
- cause is still rather unknown
- infection
- cytomegalovirus, rubella, herpes, syphilis, toxoplasmosis, zika virus, intrauterine infections, toxin exposure - infant illness
- bacterial meningitis, viral encephalitis, severe/untreated jaundice, bleeding in brain - pregnancy/birth
- low birth weight (incl. pre-term birth) - babies born <33wks = up to 30x higher CP rate
- intrauterine growth restriction e.g. due to foetal infection, multiple births, maternal smoking
- in utero death of co-foetus e.g. twin or triplet
What is the prevalence of CP?
- in developed countries, 2-2.5/1000 for past 40y
- in AUS, est. 33k in total pop.
What are the similarities between Spastic, Ataxic and Dyskinetic CP?
Abnormal pattern of posture/movement
What is the Manual Ability Classification System (MACS)?
Measures child’s ability to handly objects in important ADLs e.g. during play/leisure, eating and dressing
- hand objects easily/successfully
- handles most objects but with somewhat reduced quality/speed of movement
- handles objects with difficulty, needs help to prepare/modify activity
- handles limited selection of easily managed objects in adapted situations
- does not handle objects, has severely limited ability to perform simple actions
What is the distinction between Levels I and II of the MACS?
L1: limitations in handling very small/fragile/heavy objects require fine motor control, efficient coordination in both hands.
L2: perform same actvities in L1 but quality of performance decreased/slower. Commonly try to simplify handling objects e.g. using surface for support instead of holding it in hands.
What is the distinction between L2 and L3 of MACS?
- L2: handle most objects althoguh slower/reduced quality
- L3 commonly need help to prepare for activity/require adjustments to environment as ability to reach/handly objects are limited
Degree of independence related to supportiveness of environment
What is the distinction between L3 and L4 in MACS?
- L3 can perform selected activities if situatoin is prearranged, supervised with plenty of time.
- L4 need continuous help during activity, can at best participate meaningfully in parts of activity
What is the distinction between L4 and L5 in MACS?
- L4 can perform part of activity, need help continuously
- L5 might at best participate with simple movement in special situations. E.g. pushing buttons, occasionally hold undemanding objects.
What is dyskinetic movement?
- involuntary, uncontrolled, recurring occasionally stereotyped
what are the two types of dyskinetic movement?
- Choreo-athetotic (or athetoid) movement
- “unwanted/involuntary movements
- slow/writhing/relatively continuous movements
- affect distal parts more than prox
- affects face muscles and speech - may have characteristic grimacing
- muscle tone fluctuates - dystonic movement
- reduced activity
- No single dominant pattern (flex/ext), patterns fluctuate
- can be focal/generalised
- affects prox parts more
What is ataxic movement?
Poor musc control=clumsy voluntary movements
* issues with balance/depth perception
* difficulty walking - characteristic pattern
* intention tremor
* fine motor movements difficult
* 5-10% CP have ataxic movements
What does “mixed” movement disorders mean?
- many people with CP have more than one movement disorder, esp. as severity of BI increases
- spasticity + athetosis = most common mixed presentation
What conditions are associated with CP?
Conditions present in some not all!
- more extensive the BI / motor disturbances = more likely to occur e.g. primitive reflexes
- retention of primitive reflexes
- sensory impairment
- proprioceptive impairment
- perceptual impairment
- cognitive/intellectual impairment
- speech impairment
- seizure disorders
What are primitive reflexes?
- present in infants, normal part of development
- forerunner of normal voluntary movement = aid to survival
- normal development - reflexes become integrated. In CP, MAY NOT be integrated
- unintegrated reflexes = difficult execution of functional movements
- in PA, reinforcement of reflexes not good
If they don’t have these reflexes they’re less likely to move quickly into the stage of their movement pattern needed e.g. walking, throwing, jumping/ADLS
What is the ATNR and STNR under primitive reflexes?
Asymmetrical Tonic Neck Reflex = turning baby’s head sideways, arm/leg on that side will straighten while opposite arm/leg bends
Symmetric Tonic Neck Reflex = infants head moves forwards, arms bend, legs straight. Opposite happens when head flexes backwards
What is TBI? Is there a difference with ABI?
TBI = primary/2ndary neurologic consequences of insult to brain from external force
A(acquired)BI - more common in aus
* refers to “impairment to brain regardless of cause”
* incl. TBI + non-trauma (e.g. near-drowning, asphyxiation, substance abuse etc).
–> impaired function+resulting service need = lots of overlap across conditions
* incl. stroke + MS and PD, but from Ex pov, these conditions have specific implications –> so they receive specific Tx in this course.
What is the incidence/prevalence of ABI?
- 1 in 45 aus experiences ABI = 2.2% of pop.
- 70% <65y, highest incidence 15-25y
- approx. 3/4 with ABI = male
- > 40% of people <65y with ABI, live outside major cities
What is the aetiology of ABI?
- trauma causes >50% cases
- MVA leading cause of TBI, falls are 2nd (20-30%)
- alcohol associated with 50% TBI
Provide 2 facts regarding aetiology/prevalence/incidence of ABI.
- people <65y with ABI, 97% lived in households and 3% in care accommodations
- people with ABI, often have multiple disabilities - 26% rep 4 or more disability groups
Why is incidence of ABI more common outside of major cities?
- limitation of activities available - in major cities lots of safe supervised activities - in rural areas, climbing mountains/trees etc.
There is greater exposure to events that can lead to a traumatic injury in rural areas.
What are the 3 common consequences of ABI?
- Physical impairment
- Cognitive impairment
- memory
- planning/organisation
- language/communication - Social/Behavioural Consequences
- disinhibition
- low arousal/motivation
- egocentricity
- reduced insight/self-awareness
What are the 5 additional effects of BI on PA?
- balance
- fatigue
- overuse injury
- increased skill acquisition time
- increased seizure incidence
What are the 7 different effects of BI on PA?
- decreased ROM + contracture
- learning styles
- intra-personal variability
- stereotypical movement
- RT
- cognitive impairments
- behaviorual impairments
Define decreased ROM/contracture and provide the mechanism behind it.
People with spastic hypertonia= limb ROM sig. reduced
Contractures = complete/high resistance to passive stretch of muscle from fibrosis of connective tissue of muscles/joints
Mechanism:
* Spastic hypertonia prevents movement through full ROM of affected joints
- lack of mvoement = more soft tissue fibrosis around joints (joint capsule, ligaments, tendons and muscles)
- osseous changes may occur in long run
* ataxia and athetosis, less likely cause contracture as ROM not restricted in same way.
What are some strategies for decreased ROM/contractures?
- static stretch pre/post Ex is advisable, likely useful in preventing contracture progression - 30sec+ stretch
- little evidence ROM improved by stretching - absolute changes <10deg and 95% CI mostly include zero
- Because of this + time involved in stretching properly, do not “over-prescribe” stretching routines
Define learning styles and the mechanism of it.
The way info is presented to person with BI may strongly influence whether effective learning takes place.
Mechanism:
* BI affects wide array of cerebral functions, incl. perception, spatial awareness, memory, sensory input and intellectual functioning
* which functions impaired/which not determine methods of instruction that are effective.
Which areas of the brain affect understanding and following movement instructions?
- Parietal lobe
- frontal lobe
- occipital lobe
- temporal lobe
What are some strategies/solutions for learning styles?
Experiment with diff methods:
* vid play-back
* demonstration
* verbal
* visualisation
* written
* movement guidance (or brailing)
* tactile input
Define intra-personal variability and explain the mechanism.
Severity of motor impairments can vary observably from wk-wk/day-day or even single session
mechasnism:
* muscle tone! also ataxia and athetosis affected by:
- movement speed
- head/body position
- exertion level
- temp (cold water pools, hot day)
- mood
- fatigue/lack of sleep
- illness/pain
* fluctuations materially alter ability to perform PA
What are some strategies/solutions for intra-personal variability?
Generally…
* avoid extreme temps
* movement facilitating position (i.e. head position, COM over BOS, balance aides)
Teaching new skills…
* teach at start of session - fatigue less likely to increase movement difficulty
* create relaxed atmosphere - encourage efforts/reduce fear of failure
* use transition activities - reduce speed/force required to allow person to concetrate on producing movement correctly.
Define stereotypical movements and explain the mechanism.
People with BI often have less choice in the movement - in order to perform desired movement, certain other movements have to occur at the same time.
Mechanism:
* different “movement patterns” may be affected…
- flex/ext
- poor movement differentiation
- associated reactions/movements
- mirror movement
- reflex movements (STNR and ATNR)
- neurological mechanisms underpinning - not understood well
What are some strategies/solutions for stereotypicaly movements?
Should NOT reinforce movement patterns.
Specific strategies…
* movement facilitating positioning
* reduce activity effort
* encourage development of selective/differentiated movements, over stereotypical movements
–> unilat Ex over bilat
–> instead of barbell bicep curl, use DB with alternating flex/ext pattern (avoid general flex pattern)
* strapping or voluntary stabilisation
* make movement functional for person
Be mindful of intensity - can cause tremors, reduced coordination.
Why was RT not recommended for people with spastic hypertonia?
- strength gains were thought to be insig.
- it would exacerbate high muscle tone
- high effort would reinforce poor posturing/stereotypical (undesirable) movement patterns
What does current RT research have for CP, TBI and stroke?
Increased strength
* majority of interventions = muscle strength increase in CP, TBI and stroke
* evidence strongest in Stroke –> CP –> TBI
* in CP, some dispute (associated reactions within individuals)
Strength & functioning
* increased strength = increase mobility-related functioning
* strength training + paralympic athletes
What are the suggested strength training guidelines?
Positioning joints under load in best possible load-bearing position (e.g. leg press). This may mean using unilat movements over bilat; lines of force through optimally aligned load-bearing joints.
What are some additional strenght training guidelines for people with spastic hypertonia?
Antagonistic pairs strengthen muscles least affected by high tone & stretch muscles most affects (e.g. ham-quad)
Emphasis development of strength through full ROM, esp. end range…
- pre ex - WU + stretching
- During Ex - use stretch-load-stretch pattern
- ensure ROM with Resistance = ROM w/o resistance (e..g leg ext)
Post Ex stretching
What are cognitive impairments resulting from ABI and list the 3 principal areas?
A primary characteristic of people with TBI/ABI however, people with CP also have relatively high incidence, compared with gen. pop.
Principal areas:
1. memory
2. planning + organisation
3. language +communication
Define memory problems and list the type of problems.
Almost ubiquitous among people with ABI
Types…
* short-term memory loss - remembering task just asked to do
* remembering things well-established in routine
* remembering appts, dates, schedule changes
* trouble remembering instructions to perform skill –> slow skill acquisition
What are some strategies and solutions for memory problems?
- use written program, voice recorder with written instructions - useful
- home visits, always call day of appt to confirm
- encourage diary for appts
- realistic goal-setting and patience with skill acquisition
- using physical demonstrations over verbal
- minimise schedule/time changes
- reminder features of electronic software - useful for computer literate
Define planning/organisation problems.
people with ABI…
* difficulty with realistic goal-setting for PA program
* planning and organising activty schedule
What are some strategies/solutions for planning/organisation problems?
- structured assistance with planning/organising e.g. practitioner should help work through current commitments, logistical consideration + map out written plan that can be adhered to
- reducing program complexity, esp. initial stages help adherence. (e.g. not too much Ex variety, same venue - establish a routine!)
What are some evidence-based BCS (behaviour change strategies) for people with ABI?
- goal setting
- self-monitoring
- social support
- time management
- prompting practice/follow-up
Define language/communication problems.
- overly talkative - talk for long-time, not much info
- trouble finding right word to express what they menat (dysnomia)
- speak in disorganised sentences, contain ideas that are tangential to conversation flow
- speak toorapidly to be easily understood
- difficulty coordinating muscles of speed (dysarthria)
Receptive language+communication problems relate to comprehension - interfere with fundamental elements of Ex Sci practice, including understanding instructions/gaining consent
What are some strategies/solutions to language/communication problems?
- be patient!
- work with person to help client communicate effectively with you - slow down speech, ask q’s to stay on topic, check to ensure you heard correctly, familiarising person’s speech pattern
*receptive impairments - interfere with informed consent - enlist support from sig. others.
Define behavioural characteristics (impairments).
Disinhibition:
- be impulsive, make hasty decisions/choices
- be overly friendly, disclose personal info or appear childish
- not considering repercussions of actions
- behave inappropriately in social situations
Lack of motivation/drive:
- not follow through with plans or activities
- not as cooperative or compliant as expected
Define egocentricity and reduced insight under behavioural characteristics.
egocentricity:
- not consider whether actions affect others
- may not sympathise with others
- may appear selfish or concerned with own need
- may not appear appreciative of others
Reduced insight:
- unaware of their own cognitive and physical limitations (may cause unrealistic expectations, plan, goals)
- appear unmotivated to make changes to routines, esp. in initial stages
what are some strategies/solutions for behavioural characteristics?
Be patient!!
- maintain standards for personal interaction
- okay to compromise but practitioner must feel safe and comfortable
- if client oversteps, response needs to be proportionate and firm
- entry into group situations done personally (at least first instance) - to determine rate of success
- behaviour issues may be so big, that creating self-managed, community based PA program may be unrealistic
