neuro prac mngmnt week 1 summary.pdf

1.1 clinical decision making for the neuro population clinical decision making review health condition some type of neurologic manifestation could be from a direct injury to the CNS or a disease maybe stemming from other body systems for this course: we will be focusing on (body structures) 1. activ...

1.1 clinical decision making for the neuro population clinical decision making review health condition some type of neurologic manifestation could be from a direct injury to the CNS or a disease maybe stemming from other body systems for this course: we will be focusing on (body structures) 1. activity portion of ICF 2. participation domain steps in pt/client management personal aspect is first next aspect, environment personal factors involve environment is comprised of background of person physical social motivational use ppl first language attitudinal aspects of a pt may also include includes 1. gender 2. identity 3. sex 4. age ex: pt john who had 5. social had a stroke 6. background 7. education 8. professional 9. experience, etc a stroke or pt that legal, and social structures architectural characteristics of the living environment we can manipulate environment to make it easier or harder for the pt neural plasticity.. for better or worse! 1. use it or lose it neuro pts 2. use it and improve it review chart 3. specificity take history 4. repetition matters interview 5. intensity matters observe pt (include task analyses 6. time matters then 7. salience matters ↓ screen and incorporate tests and measures (in exam portion) 8. age matters then 9. transference interpret 10. interference come up w diagnosis and prognosis (in evaluation portion) ↓ ↓ then come up w POC (modification may need to be made ex: stroke pt- good prognosis may not need consistent modifications thru out duration of PT (PTA can treat in this case) -pta’s can progress and regress tasks w/in POC they just cant made modifications to actual plan ↓ interventions for pt are then developed and based on POC that PT set L once pt has met goals then we do a re-evalv to assess outcomes A once pt is ready then they can be discharged w a structures plan for continued learning at home (if not they continue cycle) plan of care synapses mods & neuronal sprouting occurs in addition to neurotransmitter and neural receptor changes in response to behavioral nuances neuroplasticity important bc our behaviors, interventions and learning principles that we provide our pts can LITERALLY change the brain for the better (or worse) coming up w POC we need to do our best to tap into neural plasticity need to recognize when compensatory strategies may outweigh the main regard for neural plasticity we continually need to weight the aspects related to the pt such as: potential for recovery ex: if pt doesnt have capacity for comorbidities motor learning, we need to take that precautions into account and utilize more social determinants of health compensation & life style factors in order to come up w appropriate interventions potential for recovery? 1. recognize pts potential for recovery (achieve as close to baseline as possible) need to take age and disease progression into account bc it affects neural plasticity ex: pt if pt has progressive disease: consider how long and what stage of diseases they’re in ex: stage of tissue healing they’re in consider level of fxn ex: if the person was ambulating before 2. put pt in high, medium or low category for recovery potential (regardless of RP we need to assess comorbid conditions and precautions) ex: pt high RP but is NWB for 8 weeks at hip, knee and ankles-hemiparetic limb.. these are their precautions which decrease availability for recovery based interventions *always determine lifestyle and SDOH regardless of pt, there will always be an ongoing maintenance and prevention protocol that we need to steer the to for as much independence as possible task or activity-specific training mechanisms fall under the category of rehab and recovery body fxns and structures interventions, or BFS for short, fall more under the compensation interventions focus on fxn PTs & other health professionals are responsible for providing interventions that will address each domain speech: falls more into the category of speech pathology social: more speech patho and psychologists more OT meaning: anxiety, depression, self esteem psychological: more speech patho but PTs, OTs & psychologists can too (PT is more indirect) emphasize carryover 1. “the usual” outpatient or home health duration/frequency imperative to teach pts/caregivers correct techniques to maximize recovery 2. OPTIMAL theory teaching importance of self-efficacy to our pts motivating pts w tasks they find important for an everyday basis 3. incorporation of home program within the daily routine helpful in fostering independence and continued practice ex: having someone who has posture issues sit upright during commercials 4. motor control/motor learning Summary incorporation of personal and environmental factors of the ICF use neural plasticity as a guide compensatory vs rehabilitation/recovery utilize “functional” activities emphasize carryover 1.2 intro to principles of neurological rehab 4 principles of neurological rehabilitation 1. deductive and inductive reasoning 2. fxnal competence: efficiently and effectively- in diff envrnmnts 3. embed models of motor behavior and neurological rehabilitation 4. motor learning and self-efficacy: in order to empower pts to stay on program deductive reasoning when an individual uses theories or concepts to guide the intervention choice inductive reasoning more real world experience to guide our decisions both serve as important processes that are integrated in fxnal competence goal: facilItate max ability for fxnal independence principle #1: continuous cycles of deductive and inductive reasoning required for a proper POC put theories we’ve learned to test when working w a pt outcome of our experiences will guide our next move sawtelle uses: mvmnt science & biomechanics, underlying neurophysiology of the condition and structure of activity based rehab to come up w a POC we can reformulate POC if necessary - this is considered inductive and deductive reasoning principle #2; goal of neurological rehab is fxnal compentence fxnal compentence consistent and efficient success w/in a mvmnt pattern we should teach pts how to neuro pts how to move as fxnal as possible mvmnt strategy plan used to carry out a task mvmnt pattern 1. 11 / / remember that -11 interventions are done specific to the pt dictated by osteokinematics of the task all done correctly just a little different necessary to recognize the variablilty of individuals, especially during interventions principle #3: fxnal competence embeds models of motor behavior and neurological rehab recognize that all aspects (domains) of ICF model fxn as an integration all domains needed for fxnal competence keep all domains in mind while designing interventions for our pts ex: stretching before an activity principle #4: fxnal competence required motor learning and self efficacy promote; motor learning, aerobic activity >> helps for motor learning studies by knapen and colleagues : 30 mins of exercise at a 60 % max HR increases production of brain derived neurotropic factor BDNF - has shown to facilitate motor learning and neuroplasticity motivation is a big factor toward having pts perform their interventions and exercise to build motivation and self efficacy, its important to allow pts to get a taste of success activities should be pt centered and allow them to make decisions about how they should train summary 1. deductive and inductive reasoning 2. fxnal competence 3. embed models of motor behavior and neurological rehabilitation 4. motor learning and self-efficacy 1.3 deductive and inductive reasoning review 1st principle of neurological rehab discusses continuous cycle of deductive and inductive reasoning use inductive reasoning by looking at evidence and guidance from experienced clinicians to guide our initial treatment interventions use deductive reasoning by trying things out and seeing how they work caveats objectivity 1. confusion about what evidence is looking at, or confounding factors w/in evidence to make it difficult to choose a proper intervention we should look at highest level of evidence to compile diff sources 2. we all have some bias on how we practice ex: concepts we learn, we may have more of an emotional attachment to theories resulting from inductive and deductive reasoning 1. muscle reeducation - theory utilizes the concept activation of the msk system theory would fit into body fxns and structures domain only ex: pt post stroke presented w ant tib weakness focus on strengthening muscle in isolation may not be efficient for neuro pts doesn’t translate to fxnal activity we need to closely mimic task w our intervention in order to modify an improper motor plan, strengthen and stretch tight muscles 2. neuro facilitation hierarchical model- looks at nervous system as decision maker involves sensory and tactile feedback to retrain muscles to “act normal” avoids compensatory strategies completely major limitations: -sometimes compensatory strategies are needed for QoL bc of limitations -there is minimal emphasis on having pt use intrinsic feedback ex: PT manually shortening weak tib ant during gait (hard to do) 3. motor learning/task-oriented training *vital* theory rooted in allowing pt to make intrinsic decisions about a task -pt will establish their own mvmnt patterns need to understand what normal mvmnt looks like in order to promote kinematic mvmnt sequences w/in pts biomechanics constraints technology technology is always advancing transcranial magnetic stimulation research as shown it be a beneficial adjunct for individuals w neurological compromise after stroke locomotor training clinical practice guidelines by journal of neurological PT recommended the use of virtual reality in combo w walking protocols to ppl following acute onset CNS injury after ~6months ex: going up step new robotic technology and exoskeletons have also enhanced our processes of inductive and deductive reasoning and give us an extra tool neuroplasticity 1. high frequency behavioral training -body wt support locomotion -constraint induced therapy 2. forced- use 3. training context (not just repetition) ex: using a harness to walk in treadmill improve neuroplasticity by using high frequency stepping interventions like constraint induced therapy (CIT) where the less involved limb is restrained in order to force the more impaired limb to perform more fxnal tasks has been shown to be very effective should encourage the more involved extremity to carry out the fxns of daily life for at least 6 to 8 hours a day for several days allows for more proprioceptive feedback to be provided to the cortex -priming the system for neuroplasticity to occur evidence has shown that repetition is very important (using motivation) spasticity also contributes to inductive and deductive reasoning defined as a velocity-dependent resistance to stretch manifests as hypertonia, hyperreflexia and clonus can manifest as a result of neurophysiologic processes of recovery recovery processes that can lead to spasticity include: - increases in the acetylcholine and presynaptic fibers, -additional receptors and postsynaptic membranes that increase the reuptake of neurotransmitter and thus response, regenerative sprouting, -collateral sprouting from adjacent intact neurons -reorganization of spinal neurons. new sprouts can throw off patterns of muscle control goal shouldn’t be made trying to reduce spasticity but we can target it indirectly imperative that we treat pts w/in the task itself and attempt to improve proprioceptive fxn using forced use, which also may aid in transient decrease in spasticity>> in turn activities can be carried out summary 1. inductive and deductive reasoning guide intervention selection 2. confounding factors inhibit ability to reason 3. theories evolve over time based on reasoning 4. technology and new knowledge regarding existing concepts help modify plans of care 1.4 motor learning for neurological rehab motor learning a set of processes associated w practice or experience leading to relatively permanent changes in the capability for responding changes take a long time to acquire thru practice and feedback require intrinsic mechanism of correction to abnormal mvmnt (why we dont put our hands on them unless they need it) motor performance more of an immediate transient response to exercise - see large improvements (dont last overtime) intrinsic feedback: helps foster self efficacy and motor learning mvment occurs by the interaction of aspects of the environment, individual and task thus factors impact outcome of mvmnt intrinsic constraints: body structure and comorbid conditions extrinsic conditions: environment- lighting and surface constraints can mean that the task needs to be broken down ex: speed.. practicing speed to a certain distance motor control and motor learning application 3 constructs of motor control 1. the task 2. the performer (individual) 3. the environment POC is feasible based on pt self perception and ability for action (meaning pt feels like they can perform the task) performer and practice can be manipulated in order to carry out the mvmnt task we need to import appropriate level of extrinsic info in order to allow for as much intrinsic feedback as possible - this is where we decided how much and what type of feedback we are giving our pt 3 major components of motor learning 1. perception of self and environment 2. creating a plan 3. plan performance includes information processing, practicing and later motor learning perception of self *review* there are a variety of intrinsic constraints (may require alternate mvmnt pattern) include neuromuscular aspects like: -sensation, reflexes tone, motor unit recruitment etc psychological constraints: alertness - memory cognition - motivation perception emotion -ability to process info biomechanical constraints body morphology alignment joint motions flexibity etc *any of these factors may alter the way a pt is able to perform a mvmnt task* explicit and implicit learning explicit learning guises and the learner is aware that they are trying to learn something as PTs we can help pts strategize and plan out mvmnt patterns ex: following recipe to bake a cake this learning happens in the: amygdala, temporal lobe, hippocampus, & diencephalon implicit learning its an unguided action that occurs subconsciously ex: riding a bike this learning happens in the: prefrontal and association cortices, BG (mostly) and cerebellum (mostly) for this learning we would provide opportunities for extensive task practice such that the motor mvmnts become more subconscious stages of motor learning 1. cognitive 2. associative 3. autonomous cognitive: requires most processing to occur and utilizes a lot of extrinsic feedback w little to no intrinsic feedback associative: more balance bw intrinsic and extrinsic feedback autonomous: requires little attention during mvmnt and theres intrinsic feedback to correct deviations (no outside cues) environment progressions and regressions can occur w/in tasks by using gentiles taxonomy gentiles taxonomy: provides an easy way to note the difficulty of a task & either make it easier or harder clinician can either transition more towards the R of the chart or further down to make task more difficult hardest situation is bottom R in blue green boxes creating a motor plan important to include pt in process before task starts, during task and after it ends 2 see what motivated your pt and meet them in the middle ex: pt CVA w R hemiplegia trying to crush a cup ask q’s like: how does your hand feel when you squeeze too tight? this would help create self efficacy (then provide suggestions) sawtelle technique: having pt feel like they are falling bc it gives them a way to strategize intrinsically lol dont let em fall task performance, info processing and practice 1. believe in capacity to change (v important) 2. understand intrinsic constraints 3. detect relevant info 4. create mvmnt strategies 5. select mvmnt patterns 6. analyze results 7. asses how well they performed 8. choose corrections 9. reassess outcome of next attempt components that pts must recognize before, during and after carrying out a task 10. refine and diversify mvmnt pattern augmented intervention 1. verbal, visual, environmental or tactile/manual cueing 2. knowledge of performance vs knowledge of results 3. extrinsic feedback: good improving motor performance avoid excessive feedback that inhibits motor learning 4. allow for visual observation of errors: video or mirror 5. break up the task into parts if needed aka part task/practice 6. provide adaptive practice 7. promote intensity of practice 8. promote specificity of practice 9. provide manual guidance ONLY as necessary knowledge of performance improves motor performance knowledge of results (more modern): ‘yes’ you passed or ‘no’ you didnt with no details -forces pt to reflect and self correct (motoring learning) part task practice is utilized for tasks that are more discrete or serial rather than continuous adaptive practice: making task easier to promote success ex: grasping a light and big object for ppl who have weak finger flexors pts that are more medicallly fragile: watch vitals, more rest times etc neuro pts benefit from manual guidance however it should be removed so the pt can being to find their own way of achieving a mvmnt pattern summary 1. motor learning – intrinsically corrected for lasting changes a. guided by motor control b. constrained by the task, individual, and environment c. practice and feedback design d. augmented intervention design e.promote theories of neural plasticity 1.5 Designing Intervention Progressions 3 categories of intervention progressions motor learning: type of practice/feedback patterns manipulated for progression/regression (includes environment) characteristics of the mvmt or task: do task faster, slower etc other considerations such as equipment or assistance level Example Case Motor Learning Focused Transfer progression constant/concurrent feeback -> faded/bandwidth blocked strategy for memory -> serial strategy environmental changes to surface height environmental changes to open environment - promotes motor learning, decrease cueing/change it - changing the practice - lower = more challenging - more distractions Characteristics of task progression transfer toward both dir / w/o UE support transfer/ambulate w/ cognitive dual tasking transfer/ambulate with faster speed add fxnal electrical stim to ant tib during gait Progression w/ equipment/assistance decrease manual cues to supervision during transfers decrease manual cues as able to minimal assist during gait decrease pressure placed through rolling walker or remove it Summary progressions - use motor learning - using mvmt or task - using the assist level or device recall that regressions can be looked at in the same manner always adjust to pt and how they’re doing with the task For bill’s situation: adding a cane would be a progression bc trouble w/ sequencing 1.6 Movement System Dx All based on publication “Use of Movement System Diagnoses in the Management of patients with neuromuscular conditions” 1. Movement Pattern Coordination Deficit inability to coordinate an intersegmental task due to deficits in timing and sequencing mainly seen in - leg during gait - arm during grasp, mipiulation, release tasks Presentation delayed postural movement patterns in appropriate amplitude of adjustments increased posterior sway/stance key signs altered sequence of components of either sit to stand - lack DF, post ankle sway needing to take step to stabilize variable foot placement @ initial contact unsteady line of progression of swing limb slow guarded steps possible assistance needed for balance UE signs slowed/awkward reaching difficulty adjusting grip controlling force to meet task 2. Force Production Deficit inability to generate sufficient force/weakness that may be caused by dif body systems - can be considered focal, segmental, fatigue inability to initiate sit to stand/needing assistance during standing gait may need AD, may not be able to independently stand in SL stance difficulty reaching, grasping, lifting shoulders, sustaining position, maintaining force to grip object Presentation weakness: mmt scores less than 4/5 decreased ROM or speed with repetition of mvmt can be seen in fxnal tasks 3. Sensory Detection Deficit inability to execute intersegmental mvmt - due to lack of jt position/multi-sensory failure - affecting jt position sense, vision, vestib system impairment of jt position sense/protective sensation in or more limbs new visual field deficit greater than 50% Presentation failure to complete sit to stand: hyperextension of knees befor hip ext ankle instability take a step to change BOS during gait: variable foot placement, knee hyperext in stance, loss of eccentric ankle control inability/difficulty independent standing, increased sway, loss of balance w/o vision slow mvmt, incoordination during reach, grasp, release tasks , visual cueing can improve all of -... these / 4. Sensory Selection and Weighting Deficit inability to screen for & attend to appropriate sensory inputs to maintain postural orientation accurate brain info but cant efficiently/correctly use info Presentation postural instability dizziness: w/ head rot visual motion sensitivity during ambulation - deviation in line of progression & instability w. head turns worse with increased pace increased sway with abnormal postural response difficulty fxn in busy, visually stim, complex environments 5. Perceptual deficit resist correction of alignment bc of inaccurate perception of vertical orientation postural control deficits presentation sensation of falling when shifted to correct alignment neglect of involved extremities shift COM beyond limits of stability to side/backwarrds w/ WB support resist/retropulsion/lateropulsion aka pusher syndrome when being corrected 6. Fractionated movement deficit inability to fractionate mvmt bc hyperexcitability of a limb UMN presentation move in synergies unable to disassociate mvmt at one jt from another varied ability to move against gravity, slowed, inability to reverse mvmt directions - PNF patterns muscle tone mod to greater hyperexcitability 7. Hypermetria inability to grade forces appropriately for speed/distance requirements of task Presentation movements that are too large impaired coordination UNRELATED to equilibrium cerebellar dysfxn mvmts that under/overshoot target abnormal rhythm incoordination during rapid alt mvmt gait lacks fluidity/smoothness 8. Hypokinesia slowness initiating/executing mvmt, or cessation of mvmt Presentation strength to move against gravity but freeze in ongoing mvmt slowed/lacking prep in sit to stands assist to shift COM fwd posterior loss of balance absence/delayed timing of postural adjustments, inability to use strategies difficulty initiating gait, cant regulate step length mainly seen in parkinson’s but can be seen w/ other neuro conditions 9. cognitive deficit decreased cognitive ability as primary cause of mobility deficit presentation cant follow instructions to modify mvmt performance cant remember instructions Summary use of mvmt diagnoses in neuro allow PTs to link deficits to tx, targeting multiple systems involved in mvmt production 1.7 General Approaches to Neurological Rehabilitation neuro-intervention approaches rooted within inductive & deductive reasoning neuro facilitation - margaret rood: stability/mobility - jean ayres: sensory integration - signe brunnstrom: synergistic imbalances neuro developmental theory: similar to neuro facilitation, hierarchy/basis promting recovery by inhibiting abnormal mvmt strategies & facilitating the proper way to move - berta & karl bobath: facilitation of normal mvmt proprioceptive neuromuscular facilitation: resists spiral mvmt patterns to facilitate more fxn (PNF) - herman kabat & margaret knottL resistance to facilitate mvmt task oriented approaches: utilize fxnal activity as basis for intervention - motor relearning program - constrain induced movement therapy - locomotor training in practice: can use a combo of these Neurofacilitation: margaret rood, OT interested in - stability: maintain segment in fixed pos - mobility: ability for body segments to move - sensory motor integration: - controlled mobility: distal aspect WB or closed chain and weight shifts - skill: distal aspects of limbs to be free/open chain with coordinated mvmt in stable base also discusses these strategies to facilitate/inhibit abnormal mvmt strategies - jt approximation: improves stability and muscle activation - WB - compression - stretching - tapping: increases phasic contraction of muscle Case Example pt post stroke needing help w/ elbow flexion/ext using Rood approach perform open chain flexion/ext for voluntary contraction begin tapping on muscle belly clarify what jt approx is Case Example post stroke need help WB focus on UE WB for jt approximation Jean Ayers: sensory integration as basis for all learning/fxnal tasks/facilitating mvmt important for integrating all systems of the body proprioceptive input like: lifting, moving, carrying heavy objects, weighted blankets (kinda like Rood) & vibratory stimulation challenge vestib: spinning, rocking, jumping, log rolling tactile sensations: walking barefoot, sensory brushing, wash dishes oral motor sensation: chew on dif things whole body vibration: decreases tone Signe Brunnstrom: abnormal synergy patterns & stages in motor recover incorporated into intervention planning recognized abnormal flexor/extensor synergy patterns used developmental reflexes to elicit motor responses 6 stages of motor recovery post stroke want to work on activities outside of synergy pattern to build toward isolated mvmts why would we want to work out of the synergistic patterns working more on antagonist ex if someone has high tonicity? Summary 1. neurofacilitation - mechanisms to neuro rehab acquired & refined - jt approx, WB, compression, stretching, tapping - sensorimotor approach: whole body vibration, brushing, desensitization, swinging jumping rocking - working outside of abnormal synergy patterns 1.8 Neurofacilitation Principles of the Nuerodevelopmental Treatment Approach Berta & Karel Bobath developed NDT in 1984 mainly w/ cerebral palsy NDT Principles goal driven maximizing alignment & recovery of fxn fxn specific - uses general normal patterns & biomechanics for framework for examination initiated by postural examination - identify missing components of mvmt therapeutic handling using “key points of control” - decrease abnormal mvmt strategy promoting normal mvmt (product of pt, task, environment) active participation from pt Example Handling w/ NDT (why we do it) poor grading of muscle activity muscle imbalance motor fatiguability spasticity incorrect initiation of mvmt incorrect timing & sequencing says R lateral lean w/ lengthening of more involved L side key point of control: L lat lumbar flexors w/ fingers in line w/ muscle fibers input: scoop hand up toward righ to improve midline orientation & alignment 5 key points of control head & neck upper trunk lower trunk UE LE physical assistance: min, mod, max neurofacilitation: guide motion so pt perform themselves - goal: enhance postural control, stable base to build on DO NOT OVERUSE use environmental and verbal cues first remove physical cues as early as possible for intrinsic thinking Handling Techniques light touch -> deeper pressure open hand/lumbrical grip facilitate slowly move with pt Evidence (difficult to standardize) decrease tone post stroke improve ADL fxn post stroke no improvement in shldr subluxation/pain no improvement in gait Sum'mary 5 principles of NDT neurofacilitation handling key points of control limited evidence want to guide muscles to recognize correct pattern everyone is an active participant!!! 1.9 Fundamentals of Neurofacilitation and Handling Postural alignment- good alignment provides appropriate link tension for more efficient movement, optimal posture isn’t always attainable though Remember Plum line- should fall from middle of external auditory meatus THROUGH acromiocalvicular jt, BEHIND hip jt, in FRONT of knee jt, and in FRONT of ankle jt. Frontal view seated- Both shoulders, hips, and knee joints should be aligned with one another, Humerous would be in slight ER, slight FLXN and ABD Elbow flexed ahead of the shoulder Forearm PRONATION and wrist in NEUTRAL Neurofacilitation provides the ability to correct abnormal movement patterns As a PT it is important to have the ability to intrinsically correct movement pattern deficits If the patient has the capacity to, we want them to learn strategies to correct their own mistakes ASK FIRST- allow them to perform an activity, don’t limit them. Allow for active participation Observe and analyze the task and that its appropriate for them according to their condition Verbal cue Visual cue Environmental cue FACILITATION Help patients make movements easier Understand where missing components of movements are coming from Understand any abnormal movement strategies the patients use. THEN we use manual facilitation to assist patients so they know the expected proper movements. This will help them successful develop better movement patterns HANDLING key points The more we use our body to help them, the more effective and efficient we are. Understand proper body mechanics by using our core and lower extremities Allow patient to be as active as possible Use our manual contacts as a guide only Remove manual contacts as soon as possible to allow patients to intrinsically correct themselves OPEN HAND, LUMBRICALS GRIP, NO DIP FLEXION, Fingers as EXT of muscles, AVOID PALM facilitation These handling techniques mainly assist us in recognizing how much the patient is contracting during movement Lumbar Facilitation to neutral TWO approaches- front and side Scoop hands up and inward- requires slight supination of hands Block legs- ANT LAT side of tibias Chest support- V shape with thumb and first or second digit underneath clavicle Spreading of hands in the front is for facilitating opening of the chest. Thoracic Facilitation to neutral Down and In WHAT IF FACILITATION DOESN’T WORK? Cuz we suck… There may be restrictions at the spine due to prolonged and habitual sitting habits that affect the spine. NEED TO STRETCH SPINE for more range of motion to help the spine get into neutral position Mobilizations- used as a stretch, help gain range of motion, hold for seconds to minutes, reassess range of motion, facilitate as needed 1.10 Principles of Proprioceptive Neuromuscular Facilitation Herman Kabat and Margaret Knott held the philosophy that all human beings including those with disabilities have untapped potential to being successful movements need to be reinforced through practice Neuro facilitation handling occurs on muscles PNF handling occurs on both bony landmarks PNF Guiding Principles (7) Manual Contacts a technique used in order to provide resistance against a motion that a patient is trying to perform. Contact should be clear to the patient in order to avoid confusion. Body Position and Mechanics Use efficient techniques that make movements efficient rather than using upper extremity strength to resist motions Appropriate Resistance Recognize capabilities of patients. Verbal Commands Verbal cues should match the emphasis and timing of handling Visual Stimuli Incorporate cues for visual technique Traction Occurs when therapist elongates the limb or body segment away from the axis of motion of the joint which is said ti improve muscular activation Approximation compression of a joint which assists in promoting stability Timing verbal commands and resistance needs to be sequenced correctly Neurophysiological Principles Resistance delivered throughout a movement pattern in order to facilitate increased effort from a muscle group thats being tested Stretch Idea behind stretch is to cause a contraction of the agonist muscle Irradiation Theory is that the response to resistance spreads to other agonist and adjacent muscles Successive Induction resistance in one direction will strengthen the opposite direction, Opposite of previous Reciprocal Inhibition Agonist muscles contracts and antagonist muscle relaxes Techniques of PNF Rhythmic Initiation used for individuals who have difficulty initiating a movement or controlling speed, direction, or quality of movement, and also for strength building. Show active range of motion first for patient to learn the activity. Ask for help to gradually make movement into an active assistive range movement. Then resistance is given. Repeated Quick Stretch with rhyth initiation, repeated quick stretches are then given to reinforce strength of contractions throughout range of motion in different intervals of the movement Combination of Isotonics Used to build strength as well as coordination of movement. Utilizes concentric and eccentric activations. Patient is asked to do concentric movement, move into a isometric hold and activation, then into a slow controlled eccentric contraction back to baseline position Rhythmic Stabilization, AKA Stabilizing reversals Goal is to reinforce stability. Resist at different aspects and resistance directions on the body segments Reversal of Antagonist AKA dynamic reversals Coordination and strength. Patient performs a concentric motion in one diagonal and then the concentric motion in the opposite diagonal. Resistance in both directions Contract and Hold Relax Increase range of motion. Patient contracts then relaxes while therapist pushes for more range of motion. Contract and Hold are different. 1.11 PNF Handling Trunk “All human beings, including tose with disabilities, have untapped potential” KABAT 1952 PNF pattern vs PNF diagonal PATTERN is 1 Plane DIAGONAL is 2 Planes 1 plane example: scapular ant elevation 2 plane example: scapular ant elevation and posterior depression Golfer swing: need a diagonal plane of motion 4 patterns for Scapula that form two diagonals Ant Elev + Post Depression Ant Depression + Post Elev Anterior Elevation Shoulder shrug up and in towards the nose(front) Therapist gives resistance by pushing shoulders down and pull back Muscle involved: levator scapulae, rhomboids, serratus ant. Posterior Depression Shoulder downward and inward to retract the scapula Therapist gives resistance by pushing scapula up and anteriorly Muscles involved: lats, rhomboids, and serr ant Anterior Depression Shoulder depress down and scapula retracts Therapist gives resistance by pulling shoulders up and posteriorly Muscles involved: rhomboids, serr ant, and pec major and minor Posterior Elevation Shoulders shrugged up and scapula retracted towards midline Therapist gives resistance by pushing down and anteriorly Muscles involved trapezius, levator scapula Pelvic Patterns Ant Elev + Post Depression Ant Depression + Post Elev I Anterior Elevation- Muscles involved, ipsilateral internal and external obliques L Posterior Depression- Muscles involved, contralateral internal and external obliques i Anterior Depression- Muscles involved, contralateral QL Posterior Elevation- Muscles involved, Ipsilateral QL & B D I u refer to 1.11 slides for examples of PT 1.12 PNF Handling: Extremities D1 FLEXION Patient is starting in shoulder extension, internal rotation, and abduction Performs seatbelt movement while therapist provides resistance D1 EXT Patient starts in seatbelt movement position, then performs movement towards extension, abd, and IR. - think its flex, add and ER, no? Therapist provides resistance during that motion D2 FLEXION End of volleyball swing to OUT motion Therapist provides resistance during that motion D2 EXT OUT motion to End of Volleyball swing Therapist provides resistance during that motion Bilateral UE Pattern uses? Promote irradiation and help assess imbalances and symmetry issues with both sides. Increased trunk activation HIP D1 FLX Ext, abd, IR >>>> FLX , Add, ER D1 EXT Flx, Add, ER >>>>> Ext, abd, IR D2 FLX Ext, Add, ER Ballet toe front point position to Dog Pee Position D2 EXT Dog Pee Position to Ballet toe front point position CHOP AND LIFT review 1.13 Task Oriented Approach to Neurological Rehabilitation Task oriented interventions functional activity is the main component ACtivitys require active participation from patients to help establish and participate in goals as well as problem solving using intrinsic strategies to find solutions for abnormalities that delay goal completion Motor Relearning program- based around the theory that practice is needed to reduce abnormal movement patterns Patient must go through task analysis first to identify any missing components of movement before implementing interventions Feedback should be given in the form of visual and environmental feedback. Rather than to give manual cues If patients feel fearful or unsafe doing tasks, Bergs and Bolt utilization of body weight supported systems may aid the patient and help fill in for any missing components of the task CIMT (Edward Tao?) Constraint Induced Movement Therapy behavioral training intervention. Restrained less involved side. 5 components high intensity practice, Restraining less involved extremity Shaping Transfer Package Requires behavioral contract 6 hrs a day 10-14 days REQUIRED ABILITIES FOR CIMT patients need to have minimum range of motion at least 45 degrees shoulder flexion at least 20 degress elbow extension from a 90degree flexed position at least 10 degree fingers extension which includes thumb ext and abduction Grades are assigned depending on the extent of active movement. Two outcome measures from CIMT MOTOR ACTIVITY LOG and WOLF MOTOR FUNCTION TEST MAL is tested on an amount scale to have patients indicate how much they for example used their arm before their stroke. And another scale measuring how well the arm was being used to perform activities WOLF - ordinal scale 0-5 on quality of movement. assess activities LOCAL MOTOR TRAINING (LT) motor re-learning program focused on intensive task practice with emphasis on increasing the number of steps taken within the whole task Principles of Locomotor Training Maximize Lower Extremity WB Minimize use of UEs Consistent sensory input Optimize Posture and gait Kinematics Minimize Compensation 1.14 Complementary Approaches to Neurological Rehabilitation Complementary Movement Approaches - Swiss Ball - Used in combination with/ other interventions - Slow Use = Calming Effect - Fast Use = Stimulatory Effect - Creates balance challenge - Can be important adjunct to NDT, PNF, or task oriented interventions - Feldenkrais Method - Guided Certified Practitioner - Guided Sensory Feedback - Feedback via gentle movement & directed attention to improve proprioception & kinesthesia - Clock Exercise Example - Lift pelvis and rotate in clock like movements - More research is needed - Pilates/Yoga - Pilates - Exercise-based w/ focus on core, breathing, alignment & relaxation - Minimal level 1 evidence - Yoga - Full body movements in pose - Spiritual & Physical Approach - 5 core principles - Exercise, Breathing, Relaxation, Diet/Nutrition, Meditation - Preliminary evidence to support - Cerebral Palsy, Parkinson’s, Stroke, Arthritis - Tai Chi - Rhythm-function based - Focus - Mind body alignment - Deep Breathing - Yin & Yang - Yin: R Side of Body, Lower Body, Bending Forward, Mouth, Expiration - Yang: L Side of Body, Upper body, Bending Backwards, Nose, Inspiration - Good Evidence to support - Decreases Inflammation - Decreases Interleukin 6 - Tumor Necrosis Factor - Hippotherapy - Utilization of equine movement (Riding on Horse) - Increases neural motor & sensory inputs - Focus - Sensation - Alignment - Posture -Preliminary evidence to decrease spasticity - Weak Evidence; low sample size - Effective anecdotally for children - Acupunture - Based on ancient Chinese History - Acupoint meridians - Balance qi (chi) - Good evidence towards its use - Inhibits pro-inflammatory factors - Improves cognitive dysfunction in animal studies - Aquatic Therapy - Relies on buoyancy of water to create resistance - 3 Philosophies - Bad Ragaz Ring Method (BRRM) - The use of water as resistance - Halliwack Method - Focus on learning balance in water & learning to swim - Waste - Focus on meditation like practices w/ stretching as main components - Some evidence of - Balance, Strength, Functional Mobility, Endurance 1.15 Promoting Health & Wellness in Neurological Population Health Promotion in Neurology - Includes all factors, information, & activities that improve health status of a population - Physical Activity Guidelines for Adults Provides evidence based recommendations w/ regard to exercise prescription - Underestimation of disease burden w/ neurological population Imperative exercise adheres to it, decreases after effects of neurological injury or decrease speed of progression - Therapist responsibility to educate health & wellness - Multidisciplinary Approach Barriers to Health Promotion - Cost (Main Barrier) - Awareness - Transportaion - Knowledge of How - Knowledge of Where Imperative that improvement & accessibility be made for individuals to mitigate barriers Guidelines for Health in Neurology - Risk factors determined during screening - Cardiovascular, Nutritional, Falls - Risk Assessment vs. Risk Management - Risk Assessment - Utilized by determining the probability what adverse events are involved w/ individual - Risk Management - Process that applies the info received from risk assessment & screening in order to determine need for risk reduction - Fall Prevention Program - Usually within neuro community - Includes patient/client education, physical intervention, environmental adaptation - Additional Activities - Patient education on exercise, Vitamin D, avoidance of medication, visual & environmental, AD’s, footwear, vision checks - Avoid Risky Behavior - Distracted driving, swimming, sun exposure & nutrition Nutrition to Avoid Obesity - Obesity = global epidemic - Physical Activity & Exercise - Hallmark aspects of Physical Therapy - Promote Healthy Diet - Dietary recommendations should be taken into account w/ health promotion - Body Mass Index (BMI) - Healthy (18 to Health Promotion & Wellness in Neurology 1.16 Cardiovascular Fitness in the Neurological Population Cardiorespiratory Fitness - Capacity to withstand stress of exercise - Dependent on - O2 Transport, O2 Utilization - Cardiac Output (CO)- (blood pumped/min) - Stroke Volume, directly related to amount of oxygen that’s delivered to tissues - Arteriovenous difference (AVO2 diff) - Skeletal muscle extracts oxygen from blood, sends to mitochondria - Directly affects oxygen consumption - Oxygen consumption (VO2) Cardiovascular & Pulmonary Impairments - Primary Factors - Disruption of sympathetic cardiac drive following SCI - Interruption of connections w/ medulla oblongata after TBI - Direct issues w/ pulmonary muscles reduces ability to ventilate during exercise - Secondary Factors - Impaired myocardial function - Inactivity w/ decreases in WB that causes decreased capillary density & oxidative enzymes - Coexisting cardiac comorbidites - Decreased ejection fraction - How much blood left ventricle pumps out as a % - Decreased Stroke Volume - Chronotropic Incompetence - Deficit in electrical conduction of the heart - Results in inability to keep up with/ demand of exercise - Chronic Obstructive Pulmonary Disease (COPD) Neuromuscular Impairments - Primary Effects of UMN Injury - Paresis - Tone - Impaired sensation/proprioception - Postural & balance deficits - People w/ hypertonia, restricted venous return & lactate clearance - Secondary changes in musculoskeletal system - Disuse Atrophy - Flexibility Deficits - Mitochondrial Changes - Muscle Phenotype Changes - Type 1 or type 2 fibers Lifestyle Factors - Nutrition Diabetes & Impaired Glucose Tolerance accelerates risk for atherosclerosis - Smoking/Vaping - Increases HR, myocardial oxygen demand, contractility - Sedentary Lifestyle - Family & Community Support Tests of Cardiorespiratory Fitness - Maximal Tests - VO2 Max tests considered gold standard - Exercise on treadmill for 8-12 min w/ progressive increase in intensity - End test when patient unable to generate required power, limiting symptoms, unable to continue safely - Can be modified for those w/ neurological injury - Sub maximal Tests - Used for neurological rehabilitation - Astrand-Riming nomogram estimates VO2 max from HR measurements - HR response can be measured at specific sub maximal workload - 6 min walk test - Adapted Tests for Neurological Population Contraindications to Cardiovascular Testing - MI/Angina - Vessel Stenosis - Heart Surgery - Peripheral Artery Disease (PAD) - Aortic Stenosis - Cognitive Impariements - Pulmonary. Embolus (PE) - Pacemaker - Myocarditis/Pericarditis - Orthostatic Hypertension - Systemic Infection - Dizziness - Atrial/Ventricular Dysrhythmia - Severe Pain - Valvular Heart Disease - Neuro DIsorders exacerbated by exercise - Electrolyte Abnormalities - Dissecting Aneurysm - Hypertension - EKG Abnormalities - Shortness od breath - Chronic Infectious Disease Effects of Improved Cardiorespiratory Fitness - Increased exercise capacity -Improved cardiac output, enhanced cardiac contractility - Increase in capillary density, size, number mitochondria, & metabolic enzymes - Increased cardiac efficiency - Reduced respiratory effort - Targeted expiratory & inspiratory muscle training - Reduced risk factors - Cited in SCI, MS, stoke - Improved motor function - Neuroplastic Mechanistic changes - Decreased Fatigue - Increased emotional well-being - Reduction of anxiety & depression - Improved neuroplasticity - Improved memory & cognition - noted in stroke survivors - Improved QOL Exercise Prescription - If we start exercise to early, neuroplastic changes may be adversely affected - If start too late, miss the sweet spot - Within 1 month promotes improved neurogenesis - Environment - Ready access to emergency services - Temperature & indoors per patient - Exercise Schedule - Possibly adjust to medication schedules - Exercise preparation/clothing - Warming up w/ attention to vital signs - Proper clothing to avoid falls or overheating - Frequency - 3-5 times a week - Exercise Mode -Determined by motor capacity of the patient - Based on equipment available - Exercise Intensity - Vitals: Outcome Measures - Talk test - Borg Scale - Deconditioned individuals, 55-64% of HR max or 40% of HR reserve - Encouragement to continue - Promotes self efficacy & long term health 1.17 Intro to Electrophysiology in Neurological Rehabilitation Physiology - Polarity creates electrical field - Created by anodes that have a net positive charge, cathodes that are negative - Allows for electrons to flow from higher concentrations to lower - Phospholipid cell membrane - Sodium ions w/ increased concentration outside membrane - Potassium has increased on inside of membrane - Influx of sodium occurs which depolarizes cell, leads to action potential - Electrical stimulation happens this way, but by machine not body Electrophysics - Conductors vs Insulators - Conductors: materials where ions move freely Muscles are conductors, place electrodes over muscle belly - Insulators: Materials where ions do not move freely - Current - Measured in amps - Impedance (Resistance) - Refers to opposition of electron flow - Barriers to the delivery of electrical signal - Direct Current vs. Alternating Current - Direct Current: continuous flow of electrons in one direction for more than 1 second - Also known as monophasic current Alternating Current: Bi-directional flow of electrons - Also known as biphasic - Typically use this current that’s pulsatile in nature Monophasic Pulsatile Waveform Biphasic Pulsatile Waveform Electrical Stimulation Terms - Pulse Frequency - Pulse Frequency = rate at which the alternating current switches directions - AKA, Pulse Rate - Measured in Hertz (Hz) or pulse per sec (pps) - Amplitude - Measure of magnitude of current or voltage w/ respect to baseline - AKA, Intensity - Duration - Pulse Duration = Time elapsed from beginning to end of all phases - Clinical Application (Duration & Amplitude inversely related) - Ex. Increase duration, amplitude lowered - Ramp - Time from baseline to peak amplitude of a burst - Adjusted to slowly increase & decrease contractions - Symmetrical vs. Asymmetrical Waveforms - Asymmetrical - one more waveform variables differs - Ex. Different shapes - Still add up to same charge as long as they are balanced HUH 1.18 Application of Electrical Stimulation for Neurological Rehabilitation Neuromuscular Electrical Stimulation vs. Functional Electrical Stimulation - Neuromuscular Electrical Stimulation (NMES) - Activates intended muscles using intact motor neurons - Contraction stems from stimulation to motor neuron - If denervated, custom parameters are set to bypass neuron - Electrically induced bicep curl - Functional Electrical Stimulation - Use of NMES for specific function - Electrical induced bicep curl to bring cup to mouth Considerations w/ Neurological Rehabilitation Examination - Screens for innervations, skin assessment, cognitive status - EMG screening Diagnosis Specific - CVA: cognition - SCI: Autonomic Dysreflexia - CP/Parkinson’s: Implanted Devices - MS: Spasticity, Early Fatigue Functional Electrical Stimulation (FES) - Is NMES w/ a function that has a specific intention - Urinary Incontinence - Pelvic Floor muscles - Shoulder Sublaxation - Obscure, needs appropriate scapula humeral integrity - Maintenance of muscle/CV - UE function during fine/gross motor movements (Opening things, eating) - Bioness H200 - Unit that allows electrical stimulation to wrist/finger extensors & flexors to grasp/release of objects - Gait - Bioness L300 - Walkaide - Both used wirelessly to control ankle during swing phase allowing increased dorsiflexion General Parameters of FES - Frequency: 30-100 Hz - Use of higher will activate motor units more readily - Duration: 100-800 (micro) sec - On:Off Ratio: 1:3 - Ex. 5 sec on: 15 sec off - Ramp dependent on activity - Treatment Time: To Fatigue FES for Shoulder Sublaxation - GH Alignment - Electrode Placement - Supra & Post. Deltoid - Waveform - Symmetrical OR Asymmetrical Biphasic - Parameters - Amplitude: Strong Contraction (MMT = 4/5) - Ramp: 1-2 sec up/down Do we need to memorize for each limb? FES for Anterior Tibialis During Gait - Devices made for the contraction of Ant. Tib when heel lifts off a pressure switch in patients shoe - Foot Clearance - Electrode Placement - near fibular head/superficial peroneal (fibular) nerve - Over muscle belly of ant. tib - Waveform - Sym or Asym biphasic - Parameters similar to FES subluxation - Gait switch overrides the On/Off time - Duration: to fatigue - Evidence - Increased walking speed, gait symmetry, dorsiflexion during swing FES for Exercise - FES Cycling - Restorative Therapies - Usually treatment for complete SCI patients - Provided 30-60 min, 3-5x a week - Evidence - Increased maximal oxygen uptake, strength, QOL - RT-300 - Allows people to continue stimulation of LE muscles - FES Rowing - FES Elliptical In class notes: EVERYONE can throw in whatever they want d1 flex and ext- SEAT BELT