Abnormalities of tone; Ataxia, Dyscoordination, & Hyperkinetic Disorders; Hypo-Sensitivity & Hyper-Sensitivity; Sensory Re-ed and Subluxation; Reaching

Reaching and Manipulation

• The first step in reaching and manipulation involves identifying the object and its position in space.
• The second step involves creating a plan of action to interact with that object.
• Considerations for this plan include identifying body parts needed, the direction they need to move, and the object's location relative to those body parts.
• The third step involves executing the response, considering the sequence of muscle activation and coordination.
• Execution also requires accounting forces, changes in joint angles, shaping the hand to fit the object, and coordinating proximal to distal movement.

Factors Affecting Reaching and Manipulation

• Visual perceptual deficits.
• Poor motor planning.
• Praxis deficits.
• Sensory impairment.
• Decreased motor function.

Improving These Skills

• Tasks should encompass the biomechanical demands of reaching or manipulation.
• Tasks should include distal coordination, for example variety of shapes, sizes, textures to train variety of positioning of hand/digits and
• It is important to reflect on both the characteristics and the environment of items used in a person's normal day to day life, and incorporate this into therapy practices and approaches.

Classifications of Manipulation

• Translation: Moving an object from finger to palm, and vice versa.
• Shift: Finger and thumb pads move an object distally, enabling object control.
  • Examples are moving a coin to a D1-2 tip pinch, or shifting a pencil to a 3-jaw chuck position.
• Simple Rotation: Requires turning or rolling an object between finger pads and thumb.
  • For example, unscrewing a jar lid.
• Complex Rotation: Requires isolated, independent movements of the finger or thumb.
  • For example, positioning a paper clip between fingertips to attach it to papers.

Grips and Pinches

• Cylindrical Grip: Requires use of wrist, digits, thumb and arches.
• Spherical Grip: Requires use of wrist, digits, thumb and arches.
• Span Grip: Requires use of wrist, digits, thumb and arches.
• Lumbrical Grip: Requires use of wrist, digits, thumb and arches.
• Hook Grasp: Requires use of wrist, digits, thumb and arches.
• Lateral Pinch: Requires use of wrist, digits, thumb and arches.
• Tip Pinch: Requires use of wrist, digits, thumb and arches.
• 3-Jaw Chuck Pinch: Requires use of wrist, digits, thumb and arches.

Sensation Disturbance Terminology

• Paresthesia: Tingling, "pins and needles," or electrical sensation.
• Hyperalgesia: Increased pain sensation.
• Dysesthesia: Abnormal, unpleasant sensation.
  • Cutaneous dysesthesia can manifest spontaneously or as discomfort from normal touch stimuli, such as clothing.
• Allodynia: Pain in response to a stimulus not normally painful.
  • Examples are shingles, complex regional pain syndrome (CRPS).
• Exteroceptive Input: Sensory information from the body's interaction with the external environment.
• Interoceptive Input: Information about the body's internal state.
• Proprioceptive Input: Information about position sense from the body and its component parts.

Sensory Retraining or Sensory Re-Education

• Cognitive behavioral technique helping patients with nerve injury to interpret altered neural impulses.
• Repetitive neural input from sensory retraining exercises can cause plastic changes (plasticity) in the somatosensory cortex.
• Cognitive and adaptive responses to stimulation in the affected region can be improved with sensory retraining.
• The nerve regeneration is not changed through such a technique.
• Factors impacting sensory re-education effectiveness: Age, learning capacity, cognitive skills, motivation, reinforcement, incorporating meaningful graded stimuli, active participation and feedback.
• The 'Tactile Meal' means to engage all senses to strengthen the feeling of touch incorporating factors such as taste, smell, texture, and colour.

Effects of Sensation on Everyday Activity

• Deficits cause safety concerns like judging hot/cold.
• Deficits impact stereognosis & proprioception.
• Deficits require sharp objects to be minimised.
• Deficits impact on use of built-up handles to distribute grip pressure.
• Deficits impede spontaneous use, ability to sustain grasp and pinch/grip, and impede ability to re-acquire skilled movements, impeding the performance of of daily living activities.

Sensory Re-Education in Stroke Rehab

• Discrimination should increasingly change from easy to difficult as progress is obtained.
• Visual stimuli should be graded so over time it has more occluded or less vision involved.
• Repetition and feedback is key.
• Compare sensation with the unaffected hand and self-checking of accuracy.

Sensory Re-Education Techniques

• Passive Sensory Re-education: Sending a constant message from the PNS to the CNS rebuilds pathways for feeling.
  • Techniques include e-stim, pneumatic compression, thermal stimulation, massage, self-massage and vibration.
• Active Sensory Re-education: Uses localization of sensations, discrimination, proprioception, stereognosis, graphesthesia, and kinesthesia.

Sensory Differences and Rehab Techniques

• Hyposensitivity treatment: Use discrimitative sensory re-education, focus on training to remind the system how movement should feel, with the use of vision to see and provide compensation or feedback.
• Hypersensitivity treatment: Geared toward habituation, uses graded but slightly aversive, tolerable stimulation, repetition for 10 minute intervals 3-4x/day as a home exercise.
• K-Tape improves function: Can address pain from paralysis or dislocated joints.
  • It may increase tone or tension in muscle.
  • It can enable constant activation of skin receptors on the paralyzed side
  • Can improve lymphatic drainage and address stimulating issues.

Abnormalities of Tone

• Abnormalities Include :Ataxia, Dyscoordination, & Hyperkinetic Disorders
• Ataxia causes unsteadiness, incoordination and clumsiness.
• The 3 types come about via cerebellar issues in brain and can be sensory/nerves or vestibular causing ear imbalance.
• Lesions causing CVA, TBI, alcohol abuse, neurodegenerative.
• Ataxia impacts function as it presents with wide based unstable gait, not coordinate reach patterns during leisure or bathing.
• Nystagmus can impact reading.
• Many impacted will go through progressive disease therefore adaptive approaches are key. The potential contributing factor in Ineffective movement indicates difficulty in controlling various degrees of freedom.
• Consider Stabilize or eliminate a need for joints use simultaneously
• ** Interventions***
• Orthotics provide stability to decrease degree of
• Task specific orthoses
• Stabilize head on wall
• Retrain movements involve Maintain body contact with surface
• Can move upper limbs in addction
• ** Adaptive movements ***
• Contoured seating to Exercises that are weight bearing for support

Hyperkinetic Disorders

• Are abnormal involuntary movement: excessive or high, beyond kinetics

Characteristics Include

• Tremor the is regular
• Brief random motions,
• Temporarily suppressible jerks

Flaccidity

• Patient stage 1 with little muscle function
• Feels flaccid with little resistance
• May come about via sensory loss
• Assessment* May have no motor for weeks after the onset of stroke.
• ** Treatment
• No hyperextension or past 90 degrees
• Care always needed to have little irritation

Facilitation techniques need to know:

• Use of ice and other contraction to elict motion
• Skin tapping helps

Use of reflexes

• Symetricals use limb motion
• Positive pressure from ball of foot Task oriented include
• Use of Bimanually grasping for arm rotation.

Treatment and Exercise

• Elevate scapula
• towel press
• Ice helps with pain

Hypertonicity

• Prevent and causes normal stifness via fluid movements. It can disrupt the brain and damage children in the area. Assessment by
• Modified Ashworth Scale,
• Modified Tardieu Scale Theraputic interventions and weight bearing exercises help. Graditive activity and muscles are important. Air spilnts used with elbows and the use of primitive reflexes needs to be considered.