1
Q
Name and describe the 3 levels of examination
A
Functional: WHAT the can the client do?
Strategy: HOW can the client do it?
Impairments: constraints and contributing influences of individual subsystems such as hemiplegia, sensory loss, perceptual issues
2
Q
What is an important element to keep in mind during the functional exam?
A
cardio pulmonary system
Make sure to measure vital signs before, during and after functional activities
3
Q
Examples of Functional level tests
A
Activities and Balance Confidence Scale TUG Test Reach TEsts Berg Balance 6 MWT Dynamic Gait Index 9 Hole Peg Test
4
Q
Examples of Strategy level tests
A
balance strategies: ankle, hip, stepping
gait analysis
Sensory Organization Tests
motor and sensory strategies see HOW the person performs a certain task
5
Q
Body Structure/Function (Impairment) level tests
A
Rancho Los Amigos Cognitive scale Mini-Mental State Exam MoCA Geriatric Depression Scale Skin inspection endurance/ cardiopulm status (vital signs, breath and heart sounds) pain ROM flexibility strength/motor control Trunk Impairment Scale Reflexes
6
Q
Negative features of UMN syndrome
A
muscle weakness
slowness of turning on/off muscle activation
loss of dexterity
-activating muscles/deactivating
-fractionating movements
-generating appropriate forces
-coordinating muscles forces at the right time
7
Q
Positive features of UMN syndrome
A
"excess" more than what should be there reflex hyperexcitiablilty -spasticity -clonus -increased DTRs -+ Babinski
associated reactions
co-activation
8
Q
The Ashworth or Modified Ashworth or Pendulum tests are used to measure what?
A
spasticity
9
Q
Which test is the most valid for spasticity?
A
The Tardieu
10
Q
What renders the results of MMT invalid?
A
the lack of fractionated movement or the presence of spasticity
11
Q
What does UMN damage result in?
A
- weakness
- difficulty fractionating movement
- difficulty activating/deactivating muscles quickly
- difficulty regulating force production
- difficulty controlling complex, multi joint movements
- spasticity
- clonus
12
Q
What causes the significant difference between AROM and PROM?
A
probably due to weakness, inability to recruit UMN, learned non-use or pain
13
Q
What are the upper trunk initiated movements for Ryerson and Levit?
A
anterior (bring chest to knees)
posterior (look up to the ceiling)
lateral ( make a C on both sides with your trunk)
14
Q
What are the upper trunk initiated ROTATION movements?
A
flexion rotation ( bend over to tie your shoes) extension rotation (turn to pick something up from behind)
15
Q
what are the lower trunk initiated movements?
A
anterior ( booty pop)
posterior ( tuck in your stomach)
lateral (passing gas in church)
16
Q
what are the lower trunk initiated rotation movements?
A
flexion rotation (take your shoe off with your foot over the opposite knee; make sure the spine is flexing with a posterior pelvic tilt)
extension rotation ( lower spine is in extension with an anterior tilt)
17
Q
Ways to prevent edema
A
active movement
positioning in bed with a pillow or lap trays in wheelchair
massage
intermittent compression (Juzo or isotoner glove)
18
Q
Ways to prevent skin breakdown secondary to shearing
A
lack of sensation/movement cause this as well as poor nutrition and hygiene
can intervene with:
pressure relief (every 2 hours in bed; every 15 min in wheelchair)
avoid all shearing (be careful in transfers)
skin checks
educate pt and family
19
Q
interventions for loss of ROM/contractures
A
caused by immobilization, pain, perceptual neglect stretching positional dynasplints serial casting braces connective tissue work (joint mobs) medical interventions for "spasticity" tendon releases
20
Q
key concepts of painful shoulder and how we should intervene
A
avoid the development of a painful shoulder by:
- ALWAYS preparing it via scapular mobilization
- correcting of posture
- do NOT use slings
- do NOT pull on the hemiplegic arm
- WB activities and isometric control can facilitate and wake up the muscles
- some evidence for E-stim
- do NOT force painful ROM but keep it moving in painfree activities
21
Q
ways to avoid learned non-use
A
- position limb correctly for relearning
- have them lie on hemiplegic side but with it in view
- transferring to affected side
- bear weight in affected limb
22
Q
CNS damage strengthening vs. no damage strengthening
A
Those with CNS damage lack fractionation and have difficulty activation. You have to start at a different place with theses individuals. They also have synergies that may be limiting our strengthening potential. Need to be put in different positions for motor recruitment. Set up of the task is different as well
23
Q
What returns first because of bilateral innervation?
A
more proximal return rather than distal
24
Q
what is the importance of midline
A
it promotes beer balance, strength and proprioception
it is the starting point for brain to recruit
-prevents learned non-use
-first thing to teach and should be continuously reinforced
25
What is handling?
Handling is NOT passive
| it is correcting alignment, assisting movement of weak muscles and blocking "undesirable" movement
26
Name the basic facilitation techniques
1. Joint approximation
2. Tapping
3. light touch
4. visual input
5. quick icing
6. quick stretch
7. resistance
27
Name the basic inhibition techniques
1. prolonged strecth and deep pressure
2. prolonged manual contact
3. rotation
4. prolonged icing
5. neural warmth
28
Reason you would use facilitation
for patient with flaccidity you want to increase the response of their neurons and sensory input
29
reason you would use inhibition
if your patient is already doing the action and you want them to relax
30
What is flaccidity
paralysis;a state of no active motor recruitment
31
Paresis
weakness; movement impaired
32
Why do synergy movements occur?
happening because of the weakness/loss of ability to recruit certain muscles and or certain patterns of muscle activity while the ability to recruit other muscles remains
33
What do we do if there is increased resistance to passive, velocity dependent stretch?
we usually don't treat it
34
what do we do if increased resistance to passive stretch is at all speeds
then we should check the musculature and connective tissue length
35
what usually causes stiffening?
often it is trunk weakness and limited control of the trunk that leads to stiffening
36
what are the hallmarks of learning a new skill
excessive muscle activity and co-contraction
37
What causes Parkinsons?
deteriorating levels of dopamine and damage to the basal ganglia leading to decreased force generation and weakness
38
What type of exercise is beneficial to patients with PD?
```
forced exercise
intermittent bouts of intensive exercise
focus on eccentric control of extensors
LSVT BIG- large whole body movement emphasis
spinal flexibility
dual tasking
constraint focused agility exercise
```
39
What causes Multiple Sclerosis?
demyelinzation of white matter and damage to WM and GM of the CNS
40
major impairments of MS
motor fatigue and lassitude
thermosensitivity
stiffness
41
What is spasticity?
velocity dependent resistance to passive stretch
42
Flexor synergy for UE
```
Retraction and elevation of the shoulder
External rotation of the shoulder
Abduction of the shoulder to 90
Elbow flexion to an acute angle
Supination of the forearm full range
```
43
What is the dominant component of the flexor synergy for the UE?
elbow flexion
44
Extensor synergy of UE
```
fixation of the shoulder girdle in a protracted position
Internal rotation of the shoulder
Adduction of the arm
Extension of the elbow
full range pronation of the forearm
```
45
What are the dominant components of extensor synergy of the UE
Internal rotation of the shoulder
| Adduction of the arm
46
Flexor synergy of the LE
```
Flexion of the hip
Abduction and external rotation of the hip
Flexion of the knee to 90
Dorsiflexion and inversion of the ankle
Dorsiflexion of the toes
```
47
What is the dominant Flexor synergy of the LE component?
flxion of the hip
48
Extensor synergy of the LE
```
Extension of the hip
Adduction of the hip
Internal rotation of the hip
Extension of the knee
Plantarflexion of the ankle
Inversion of the ankle
Plantarflexion of the toes
```
49
What is the dominant Extensor synergy of the LE
Adduction of the hip
Extension of the knee
Plantarflexion of the ankle
50
What is the dominant synergy for each extremity?
UE- flexor synergy
LE- extensor synergy
51
stage 1 of brunnstrons stages of recovery
flaccidity of the involved limb
| no movement can be initiated
52
stage 2 of brunnstroms stages of recovery
associated reactions appear
53
stage 3 of brunnstroms
synergies begin to emerge
54
stage 4 of brunnstroms stages of recovery
some movement combinations that do not follow the basic limb synergies are mastered
more voluntary control in this stage
there are specific test movements that are used to determine if the limb is in stage 4
55
specific test movements for UE if in stage 4
- able to take hand to lumbar spine
- able to perform shoulder flexion to 90 while keeping elbow at 0
- able to pronate and supinate forearm keeping the elbow at 90 and the shoulder at 0
56
specific test movements for LE if in stage 4
- in sitting, able to flex knee past 90
| - in sitting, able to dorsiflex the ankle, leaving hip and knee in place
57
stage 5 of brunnstroms stages of recovery
more difficult combinations are mastered as the basic limb synergies lose dominance
58
UE movement tests for stage 5
- able to abduct shoulder to 90 while keeping elbow at 0 and forearm pronated
- able to flex the shoulder between 90-180 keeping the elbow at 0 and the forearm pronated
- able to pronate and supinate the forearm while keeping the elbow at 0 and shoulder between 30-90 of flexion
59
LE movements of stage 5
- in standing, flex the knee while keeping the hip at 0
| - in standing, dorsiflex the ankle while keeping the hip and knee at 0
60
stage 6 of brunnstrums stages or recovery
individual joint movements (fractionation) becomes possible and coordination approaches normalcy
61
stage 7 of brunstrumms stages of recovery
normal motor function is restored
62
what stages are associated reactions NOT present?
in stages 1 or 7 they do not occur
63
what are associated reactions
automatic tensing of muscles and involuntary limb movements created by voluntary forceful movements in other parts of the body
64
what are the common associated reactions of the UE
evoked patterns are the SAME as the resisted movement
ex: resisted flexion of the uninvolved side yields flexion on the more involved side
65
common associated reactions of LE
evoked patterns are the OPPOSITE as the resisted movement
ex: resisted flexion on the less involved side yields extension of the more involved side
66
what is homolateral limb synkinesis
flexion of the LE evokes flexion in the UE
| occurs because this is just the way we are wired
67
what is raimistes phenomenon
opposing abduction on the less involved side causes the more involved LE to abduct
adduction may be accompanied by internal rotation
68
what is souques phenomenon
passive elevation of the shoulder to 90 flexion can open the hand
69
what type of movements are NOT classifed as coordination problems?
involuntary movements such as chorea, resting tremoer, dystonia and hemiballismus
70
list coordination problems
```
lack of accuracy/scaling deficit (hypometric, hypermetric)
intention tremor
decomposition of movement
delays in timing
sequence deficits
eye-hand coordination issues
ataxia
proximal weakness
conscious somatosensory loss
apraxia
```
71
2 different aspects ofdecompositon of movement
dysdaidochokinesia
lack of sequence length effect
-movement is accomplished in segments rather than one fluid movement
72
what is ataxia
lack of coordination resulting in unsteadiness of gait or movement
73
what is spinal ataxia
"sensory" ataxia
there is a lack of sensory input to the cerebellum which results in a broad base gait, flailing movements of the feet.
these individuals tend to do better with their eyes open so they can watch their feet
74
what is cerebellar ataxia
all the information is there bt it just is not being processed
these individuals do just as poorly with their eyes open as they do with their eyes closed
they are unable to walk tandem or follow a straight line
75
general guidelines for impairment level examining
-pt must have:
isolated movments
adequate strength, ROM, stabilization
-examine sensation first because this can be contributing to incoordination and change the prognosis/intervention
-tests need to be done at different speeds and ranges
76
what are apraxias?
NOT a coordination deficit
it is a disorder of skilled movement; inability to execute intentional movements in absences of paralysis, weakness or other sensory,cignitive, or motor impairments
77
examples of apraxias
ideomotor- inability to carry out on verbal command an activity that can be performed well spontaneously
ideational- difficulty sequencing motor acts; not able to put the motor plan togehter, may use objects inappropriately
visuconstructional-difficulty in task that involve putting objects together
dressing- lack of understanding of the relationship between ones one body and spatial relationships
oral- difficulty in forming and organizing intelligible words although the musculature required to do so is intact
78
limb kinetic apraxia
slowness and stiffness of movements with a loss of fine, precise and independent movements of the fingers
79
what is dysmetria
inability to judge the distance or range of a movement
80
coordination tests for dysmetria
pointing and past pointing
drawing a circle or figure eight
heel on shin
placing feet on floor markers
81
what is dysdiadochokinesia
cerebellar pathology
| impaired ability to perform rapid alternating movements
82
dysdiadochokinesia coordination tests
```
finger to nose
alternate nose to finger
pronation/suoination
knee flexion/extension
walking with alterations in speed or direction
```
83
movement decomposition coordination tests
finger to nose
finger to therapists finger
alternate heel to knee
toe to examiners finger
84
what is hypotonia
cerebellar pathology
| decreased muscle tone
85
hypotonia coordination tests
passive movement
| deep tendon reflex
86
what is an intention tremor
oscillatory movement during voluntary motion; increases as the limb nears target
87
intention tremor coordination tests
```
observation during functional activites
alternate nose to finger
finger to finger
finger to therapists finger
toe to examiners finger
```
88
bradykinesia coordination tests
walking, observation of arm swing
walking, alter speed and direction
request that a movement or gait activity be stopped aruptly
observation of functional activies: timed tests
89
what is rigidity
increase in muscle tone causing greater resistance to passive movement
90
nonequilibrium coordination tests
```
finger to nose
finger to therapists finger
finger to finger
alternating nose to finger
finger oppositon
mass grasp
pronation/supination
rebound test
tapping
point and past pointing
```
91
what is frenkels exercises used for
used for coordination
92
what can weakness come from?
```
UMN lesion
LMN lesion
muscles diseases
cerebellar leasions
disuse
```
93
what is demanded by MMT?
isolated muscle control (fractionated movement)
94
what is hypertonicity
increased tone
many individuals systems recruit more UMN/LMNs than are mechanically necessary for maintaining a position or posture for stabilizing one part of the body while moving another part
95
what is rigidity
neurologically caused resistance to passive movement INDEPENDENT of velocity of the passive movement
96
what are possible sources of this resistance?
changes in mechanical-elastic resistance
increases in segmental level stretch reflex activity
inability to voluntarily relax muscles or extreme slowness in relaxing muscles
97
What would be an appropriate initial intervention to address strength for an individual with a flaccid limb?
- establishment of stability in a functional position (sidelying, sitting, standing, rolling side to side, supine to sitting, transfers, sit to stand)
- task oriented activities
- use facilitation techniques- joint approx, quick stretch..
- WB through the flaccid limb
- prevent learned non-use
98
What type of work would you use to work on strength with a patient with weakness that can produce isometric contractions and WHY?
You would perform ECCENTRIC work because this utilizes elastic elements and muscle spindle support more efficiently. Concentric work is not advised because it would cause a synergy to occur
99
What is an activity that can serve as either a facilitation technique or an inhibition technique?
WEIGHT BEARING
100
What are the motor control problems of someone with CEREBELLAR damage?
```
asthenia
asynergia
delayed reaction time
dysdiadochokinesia
dysarthria
dysmetria
dyssynergia
ataxic gait
hypotonia
hyper/hypometria
psotural instability
tremor (intention/postural)
```
101
What are the motor control problems of someone with BASAL GANGLIA damage?
```
Akinesia
Athetosis
Bradykinesia
Chorea
Choreathetosis
dystonia
hemiballismus
hyperkinesis
```
102
4 factors that contribute to motor learning
arousal
attention
motivation
memory
103
When should feedback be given?
before a new task
104
What type of extrinsic feedback enhances learning?
terminal feedback; given at the end
105
Knowledge of Results
extrinsic feedback given at the conclusion of a task regarding the outcome
106
Knowledge of Performance
extrinsic feedback regarding the movement pattern used to achieve the goal
107
Which is better; distributed or massed?
DISTRIBUTED; there is more rest time than practice
108
Which is better; random or blocked?
RANDOM; practice the sequence in a variety of tasks at random across trials instead of repeatedly and uninterrupted is better
109
Which is better; whole or part?
WHOLE;practicing the entire task at one time instead of learning it separately is better
110
Gentile Task Analysis; environmental context
stationary- movement is self paced
motion- surface underneath is moving
no intertrial variability- sit to stand with same chair repetitively
intertrial variability- sitting on a chair of different heights
111
Gentile Task Analysis; functional context
body stability
body transport
no object manipulation
object manipulation
112
What is the significance of Gentile Task Analysis?
this system provides us a way to more fully characterize a patients functional abilities, recognize deficits and plan appropriate treatment
113
What is a control parameter?
a variable that shifts behavior from one form to another
| ex: speed of the treadmill
114
What are affordances?
possibilities that an object provides
115
what are constraints?
characteristics of an element in a system that limits or restricts the behavior
116
What is the significance of handling?
- helps us gain insight about the cause of pts. movement difficulties and how responsive they are to our handling
- we can gather info. about their strength, control an impairments
- forces the pt. to initiate movement
117
What is the significance of facilitation and inhibition techniques?
Used to change LMN response by using sensory inputs to elicit an increase (facilitation) or decrease (inhibition) in muscle activity
118
Hoehn and Yahr Stages of PD
```
Stage One
Signs and symptoms on one side only
Symptoms mild
Symptoms inconvenient but not disabling
Usually presents with tremor of one limb
Friends have noticed changes in posture, locomotion and facial expression
```
Stage Two
Symptoms are bilateral
Minimal disability
Posture and gait affected
Stage Three
Significant slowing of body movements
Early impairment of equilibrium on walking or standing
Generalized dysfunction that is moderately severe
```
Stage Four
Severe symptoms
Can still walk to a limited extent
Rigidity and bradykinesia
No longer able to live alone
Tremor may be less than earlier stages
```
```
Stage Five
Cachectic stage
Invalidism complete
Cannot stand or walk
Requires constant nursing care
```
119
What are the ROM limitations of Decorticate
Because this patient is demonstrating grossly flexed UE and LEs you will see limitations with extension
120
What are the ROM limitations of Decerebrate
Because this patient is demonstrating strong extension posturing you will see limitations with flexion
121
What things are you observing when performing Ryerson and Levit movements?
- starting position of the body
- asymmetries in weight distribution
- postural deviations
- differences between the two sides
- initiation phase of the movement
- weight shifts
- transition point
- completion of the movement
- range of movement control
- qualities of the movement pattern such as speed smoothness and ease of moving
122
What are the 5 stages of Hedmans temporal sequence analysis?
initial conditions (posture, environment interaction)
preparation( response selection and programming)
initiation (timing, direction, smoothness)
execution (amplitude, direction, speed, smoothness)
termination (timing, stability, smoothness)
123
What is the significance of Hedmans temporal sequence analysis?
This observational analysis guides the clinician to specifically target the stages where the movement is compromised and to generate ideas for intervention. Additionally, it guides the clinician to identify the nature of the problem with movement (eg, direction, amplitude) at each stage further refining decisions regarding the optimal approach to intervention.
Adult Neuro
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