Spinal Curves and Tracts

• Normal spinal curves include cervical and lumbar lordosis (concavity) and thoracic and sacrococcygeal kyphosis (convexity).
• The vertebral column has a triaxial joint that has movement in 3 planes
• Related bony structures include the pelvis and rib cage, which move with respirations and in concert with the spine
• Lateral & Anterior Corticospinal Tract initiates signals in the brain that descend to lower motor neurons innervating muscles
• Medial Reticulospinal Tract is important for balance and postural adjustments, originating in the brainstem and descending pathway
• Lateral Reticulospinal Tract is active during walking and stimulates flexors, descending bilaterally and inhibiting the medial reticulospinal tract
• Vestibulospinal Tract originates in the vestibular nuclei and leads to the pons to communicate changes in head position and is responsive to adjustments

Rectus Abdominis & Obliques

• Contraction causes flexion, posterior pelvic tilt, and straightening of lumbar lordosis
• External Obliques causes contralateral rotation during unilateral contraction
• Bilateral contraction assists with trunk flexion.
• Internal Oblique unilateral contractions assist in ipsilateral rotation
• Transverse Abdominis is innervated by the ventral primary rami of the spine

Erector Spinae

• Bilateral contraction causes extension, anterior pelvic tilt, and increased lumbar curve
• The trunk extensors innervated by dorsal primary rami, assist with lateral flexion and rotation to balance abdominals
• Latissimus Doris acts unilaterally on the humerus and assists with lateral flexion, bilaterally causes spinal hyperextension and anterior pelvic tilt
• Quadratus Lumborum unilateral contraction elevates the ipsilateral side of the pelvis (hip hiking) and lateral flexion; bilateral contraction assists lumbar extension

Sitting Posture

• Pelvis exhibits neutral tilt and rotation, with equal weight-bearing on ischial tuberosities (ITs)
• The spine is straight and vertical with appropriate curves
• Ribs are in neutral alignment between hips and shoulders
• Shoulders are at even height and above the pelvis
• UEs have minimal or no weight bearing, remain relaxed and ready to move
• LEs are in a 90-90-90 position, knees aligned with hips, feet under knees

Lateral Trunk Flexor Control

• Eccentric control (on the elongated side) is isometric during lateral flexion while holding at the mid-to-end range
• Concentric controls are present when one returns to neutral from lateral flexion, or when the patient shifts weight from hip to shoulder
• Anterior pelvic tilt presents with PSIS higher, tight hip flexors, and potential obesity
• Posterior Pelvic Tilt presents with a higher ASIS, tight extensors, and kyphosis of the thoracic trunk
• Pelvic Obliquity is when one side of the pelvis is higher than the other, and is named for which side is lower
• Anticipatory Mechanism involves postural adjustments made before movement and improves with experience and practice
• Compensatory Mechanism involves postural adjustments in response to sensory awareness and the experience of loss of balance
• The center of Gravity is at approximately S2, hypothetical point where all body mass is concentrated and where the forces from gravity act
• The line of Gravity is the direction of the force of gravity, which is always vertically downward
• Pusher Syndrome is an altered perception of vertical body seen in patients with R or L unilateral stroke in the posterolateral thalamus
• Patients push with their strong side toward their weak side

Joints

• The Sternoclavicular Joint is a synovial, saddle joint with its sternal end of clavicle articulating with the acromial process allowing elevation/depression, protraction/retraction, and some rotation
• Acromioclavicular Joint: synovial, acromial end of clavicle articulates with acromion process of scapular, upward/downward rotation, internal/external rotation, anterior/posterior tilting
• Glenohumeral Joint is a true synovial, ball & socket joint, in congruous joint, where the head of the humerus articulates with the glenoid fossa of the scapula, flexion/extension, abduction/adduction, internal/external rotation

Additional Glenohumeral Joint notes

• External rotation and lateral scapular rotation are necessary to achieve full arm elevation in abduction

• Glenoid Labrum deepens the joint capsule to enable attachments for the Glenohumeral ligaments and adds depth to the joint

• Bicep Brachii with a long head, is located in the GH joint, which holds down or depresses the numeral head and flexes the elbow joint

• Impingement Syndrome presents as compression of the greater tuberosity against the contents of the subacromial space

• Overzealous ROM above 90 degrees without scapular movement

• Shoulder Subluxation results when shoulder ligaments fail to support arm weight, measure using finger spaces classified between the acromion & humeral head and is classified as anterior, inferior, or superior location

• CNS is organized hierarchically meaning higher bain centers control lower brain center and the PNS

Levels of CNS Control

• Highest Level: Motivation, Ideation (goal)
• Middle Level: Programming the motor planning
• Lowest Level: Execution (and maintenance) of movement

Rood Approach

• Key components include normalizing tone, sensorimotor stimulation, and developmental postures to promote changes in muscle tone (proximal to distal)
• Treatment begins at the developmental level of functioning
• Facilitation: light moving touch, icing, fast brushing
• Inhibition: gentle shaking or rocking
• Limitation: Not for function- or occupation-based

Brunnstrom Movement Therapy

• The primary goal of treatment is movement of the patient through the 6 stages of recovery in adult hemiplegic population
• Stage 1: flaccid stage with no voluntary muscle movement
• Stage 2: developing spasticity and syngergies with little to no active finger flexion
• Stage 3: synergy dominant with mass of hook grasp
• Stage 4: spasticity is beginning to decrease
• Stage 5: synergy no longer dominates
• Stage 6: isolated motor movement almost from synergy and spasticity
• Proprioceptive Neuromuscular Facilitation (PNF) is a dynamic approach to treatment of neuromusculoskeletal dysfunction emphasized on the trunk
• Evaluates dynamic strength, flexibility, and coordination with an emphasis on muscle recruitment and motor control
• Focuses on reeducation of normal movement and motor development by improving trunk control, stability, coordinated mobility (diagonals) and contract/hold relax

Neurodevelopmental Treatment NDT

• The primary goal is to retrain normal movement on the hemiplegic side
• Alignment and symmetry of the trunk and pelvis are necessary for good alignment/symmetry of extremities
• Facilitation Techniques provide sensation of normal movement, stimulate muscles to contract, practice constrained movement, and use involved side

Upper Extremity Stroke Management

• Shoulder abduction and internal rotation should not occur
• Scapula, humerus, and clavicle should work together for full abduction range of motion; a roll and slide act with the deltoid pulling up and supraspinatus pulling in
• Impingement Test: internally rotate thumb down along with extended elbow, during scaption subacromial impingement in anterior pain, posterior pain is internal impingement
• Hawkins-Kennedy: Passively externally rotate, with elbow flexed at 90, internally rotate the elbow
• Self ROM should involve dangling arm to the floor, wiping a table with a towel, cradling a baby, forearm weight bearing with rotation away, relaxing at the beach (only if cognitively intact), supine to side lying
• Inferior shoulder subluxation presents as downward rotation of the scapula
• Anterior shoulder subluxation presents as scapula downward rotation with inferior angle tipping
• Superior shoulder subluxation presents as scapular elevation, shoulder IR and abduction and elbow extension
• Hemi-slings provide support on the anterior aspect of the shoulder and proximal arm
• Givmohr slings improve balance, gait, and proprioception to the UE
• Muscle tone is resistance to stretch within a resting muscle
• Spasticity is resistance to PROM in one direction, velocity dependent, and includes hyperreflexia, clonus, babinski
• Rigidity presents as resistance to PROM in either direction and is velocity independent
• Constraint Induced Movement Therapy given for 6hrs per day for a period of 2-3 weeks with a mitt worn during daily activity (ADLs)
• Mirror therapy to be used for paretic UEs

Edema Post Stroke

• Lymphatic System Main has the function to get rid of the body's toxins
• Starling's Forces -hydrostatic pressure, oncotic pressure, capillary, and interstitium
• Starlings Law: fluid movement across the capillary wall with the function of rid body of toxins

Forms of stroke hand edema

• Types include dependency, combined, micro, pitting
• Manual Edema Mobilization is used for later/combined edema because it congested the lymph system
• Diaphragmatic breathing, trunk ROM, massage
• Low Elastic (high working pressure) and Elastic High Stretch (low working pressure) forms include Comprilan/Rosidal, Ace wrap, and Coban

Pain Classifications

• Acute Pain: less than 6 months, underlying pathology, well localized
• Chronic Pain: may start as acute pain, persists beyond normal time for tissue healing
• Nociceptive Pain: noxious stimuli, with ongoing tissue damage
• Neuropathic: peripheral or CNS dysfunction, without ongoing tissue damage
• Referred pain is an experience in a different area
• Nociceptors are pain receptor (thermal mechanical, chemical, silent, polymodal)
• Neospinothalamic and Paleospinothalamic
• Gate Theory: lack of large fiber input can open the gate of pain impulses ex Rubbing skin after stubbing toe

Complex Regional Pain Syndrome

• Type 1: RSD

• Type 2: Causalgia

• CRPS Treatment: stress loading, mirror therapy, motor imagery, desensitization, manual massage, compression, elevation, weight bearing, gentle AROM

• BEFAST assessment

• Left hemisphere: (logic, analysis, math, language)

• Right hemisphere: (creativity, imagination, arts, rhythm, feelings)

• Frontal Lobe: (movement execution, planning, sequencing, planning, judgment, emotion

• Parietal: fine touch, spatial awareness

• Temporal: auditory, language, long term memory, emotion, motivation, personality

• occipital lobe: visual processing

• Cerebellum: coordination

Stroke Classifications

• Ischemic Stroke: mechanical obstruction of vessel (80% of strokes) include Embolic, Thrombotic & Antherothrombotic, Lacunar
• TIA: transient, sudden, lasts 1hr
• Signs of Cortical Lesion including UMN, Dyskinesia, Dyssynergia

Potential Deficits from MCA Infarct

• Motor apraxia bilaterally

• L sided decreased sensation

• R sided decreased sensation including pain, temperature, discrimination and proprioception

• Spatial and perceptual deficits

• Homonymous hemianopia

• Blind spots in the visual field on the right

• R-sided hemiplegia or hemoparesis

• Aphasia/Language deficits

• Slow or cautious personality Possible Deficits from PCA Infarct: Cortical blindness, Amnesia, Hemianopia, Visual Agnosia, Visual Spatial Impairment, Acalculia, agraphia, reading deficits

• Motor Learning is the acquisition and modification of learned movement

• Motor Control is the outcome of motor learning that involves the ability to produce purposeful movement in response to environmental demands Approach: active participation and repetition to foster learning

• Dynamic Systems Theory of Motor Control the motor behavior is a dynamic interaction between client factors, contexts, and roles

• Movement/control is a result of interaction between all systems Task-Oriented OT task performance (occupation) depends on demands and the environment.

• The occupation based recovery according to the dynamic systems theory is that recovery is variable

Carr & Shepherd ML/MC Approach

• Recovery does not necessarily proceed in a proximal to distal sequence
• Challenge to active limb use doesn't need to wait for spasticity to inhibit
• There are no universal patterns of muscle linkages when brain injury recovery
• Improve motor patterns are based on patient abilities

Stages & Types of Learning

• Stages: cognitive, associative, autonomous
• acquisition/retention/transfer phase
• Types: Intrinsic and Extrinsic feedback
• Types of Practice:
  • Distributed-trial intervals equal to or greater than trial time
  • Massed-trial intervals less than trial time
  • Block practice-repetitive trial
  • Distributed is better for initial acquisition, massed is better for long term goals Therapeutic techniques include:
• constant, repetitive practice; varied and personalized practice; whole practice
• constant practice is done the same way every time; variable alters the tool/environment to complete
• Summary Knowledge of Results: fade feedback after task instead of after individual performance.