Neuro wk 5 Summary PDF

5.1 Manual Interventions For Flaccidity and Hypotonia Hypotonia and Flaccidity- genetic, mitochondrial, cns etiologies NOT postural tone. Postural tone is amount of tension needed to maintain upright position against gravity Hypotonicity refers to those who have SOME DEGREE of tone, but is less than...

5.1 Manual Interventions For Flaccidity and Hypotonia Hypotonia and Flaccidity- genetic, mitochondrial, cns etiologies NOT postural tone. Postural tone is amount of tension needed to maintain upright position against gravity Hypotonicity refers to those who have SOME DEGREE of tone, but is less than normal. Flaccidity refers to those who lack muscle tone Keep joints safe, mobilization would make the condition worse. REVIEW: Muscle tone is influenced by neuromuscular and musculoskeletal componenets Neuro intrafusal muscle fibers of the muscle spindle detect changes of muscle link sending impulses to the spinal cord then the brain to monitor muscle stretch Brainstem, cerebrum, cerebellum, basal ganglia, descending nerve pathways, ant horn cells, peripheral nerves, and the neuromuscular junction ALL PLAY A ROLE Example: Patient with foot drop. We want to put electrical stimulation. Is Injury Central or Peripheral ? IF CENTRAL- then electrical stim for peripheral nerve is appropriate IF PERIPHERAL- then muscle is denervated, then peripheral nerve can’t depolarize to cause a contraction of muscle. Electrical stim is still feasible but with different parameters Examination Standpoint most outcome measures in infants Modified Ashworth is for HYPERtonia or INCREASED tone. SO NO Passive Range of Motion Observation Palpation Skills ascertain the number of finger widths for subluxation General Interventions Facilitatory stimulation Scooping Joint approximation gives joint feedback to the brain for awareness of limb Weightbearing technique by using hands to press joints into the floor All interventions need to be within realistic expectations and within a certain function 5.2 Alternative Interventions- Flaccidity and Hypotonia Equipment- Slings, Splints/Positioning Devices, Tabletop/support (For patients with subluxation and general joint laxity) Slings- Understand that the sling puts shoulder in IR, and ADD with Elbows also in FLXN. This can cause tightness for the patient and would shorten muscles leading to contractures. Does not approximate the joints to reduce subluxation. GiveMohr Sling is a much better alternative. Figure 8 design that provides approximation support Should be used for upright ambulation, standing, and transfers can’t be used sitting Splints and Positioning devices are provided by OTs Tabletop support wheelchair lap trays used in combination with tape Cushions will approximate the glenohumeral joint in a seated position Tape UE- decease incidence of subluxation McConnell/Endura/Leuko Tape. NOT KINESIO TAPE Kinesio tape has give and is stretchy. can be used in combination with electrical stimulation for added benefits Taping Method revolves around using bony prominences as anchors. Electrical Stimulation - Alphamotor neuron stimulated to help with contractions FES with flaccidity in UE patients have shown active control and improvements in tone with task training , NMES- used to decrease subluxation BIONESS- UE device to activate wrist and finger flexors and extensors for fine motor tasks WALKAIDE- shoe insert to be triggered from heel lift to stimulate ant tibialis Vibration sinusoidal oscillations throughout the whole body to stimulate mechanical receptors AND vestibular system Cerebral activation in the sensory cortex and thalamus Vibrations alter neurotransmitter concentrations: dopamine and serotonin Adults with MS, spinal cord injury, and CVA have shown strength improvements and torque production. Motor function too Mirror Therapy Mirror used in sagittal plane placed between limbs. Non paretic limb movements make the paretic limb appear as if they are functioning normally. Theory: observation of movements and performance share similar cortical areas in the brain In watching an activity being done by the more involved limb. This would help stimulate the same areas. Moderate effectiveness for UE 5.3 interventions for hypertonia review of terms hypertonicity: any increase in muscle tone spasticity: velocity dependent resistance to stretch agonist muscle: resistance to passive high speed resistance dystonia: involuntary or sustained posturing due to damage to cortex rigidity; resistance to stretch independent of velocity lead pipe: resistance to one fluid motion cogwheel: catch and release of resistance pathophysiology spastic hypertonicity: damage to UMNs prim and sec motor cortex corona radiata corticospinal tracts of bs ventral thalamus spasticity: damage to post limb of internal capsule (descending pathways of UMNs w/in lat corticospinal tract) spasticity thought to occur due to hypersensitivity of reflex arc due to changes in CNS related to loss of descending inhibition from cortex rigid hypertonicity: damage to BG (substantia nigra)push downward on dorsal aspect of MCP to distract support needed at wrist and forearm during activity bc hand will curl back up extend thumb, PIP/DIPs: while MCP jnts in flexion allows greater ease to achieve extension always want to maintain arches of hand extend MPs & provide WB -foam roller or towel can be used -inhibitory feedback: a. deep pressure to stimulate GTO activation, jnt traction & rhythmic rotation mvmnts rehab interventions taping: kinesiotape- control jnt positions & improve jnt proprioception a. applied perpendicular to muscle fibers biofeedback: so pt actively contracts antagonist muscle to reduce agonist hypertonicity whole body vibration: normalize muscle tone a. used for both hypo/hypertonia estem: applied to antagonist muscle to cause them to contract & override agonist stimulus FES cycling: stimulate agonist & antagonist aquatic exercise: improve strength, motor control & balance a. decrease effects of rigidity trager therapy: gentle rocking provided to body to decrease rigidity a. improved effects when pt in supine other interventions: acupuncture summary hypertonicity - spasticity = velocity dependent - rigidity = velocity independent - dystonia = variable presentation - direct Interventions o pharmacology - rehabilitative Interventions o weightbearing o inhibition o cycling o electrical Stimulation o vibration o taping 5.4 interventions for contraversive pushing contraversive/ipsi pushing (pushers syndrome) occurs in 20% of pts post stroke good prognosis longer recovery time for fxnal gains (in comparison to pt who doesnt have pushers) -pushing is severe in beginning *watch video* pt pushes himself w his foot & cant right himself back into neutral general approaches to tx contraversive pusher syndrome -environmental cues/orientation -visual feedback -tactile feedback for perceptual deficit *AVOID PUSHING BACK*: causes them to push to paretic side more frequent redirection & orientation guide not push goal: have pt ACTIVELY move toward non-paretic side - l rehab interventions alignment in midline *key* a. once position maintained>>wt shift toward non-paretic side wt shifting using visual feedback remove pushing extremity: so they dont use bc it can make it worse a. could have pt hold their own arm b.constant redirection use of environment a. straight lines/objects b. tape lines on wall c. tactile feedback from tables transfer toward paretic (pts w NO pusher syn) -promotes forces use & increasecortical excitability for neural for visual alignment & wt shift for gait plasticity of more involved side pushers: increased cortical excitability + recognize midline mobility & wt shift (for limbs> controlled mobility> skill pts w good prognosis for static sitting w/o external aids/assistance WB extremities used for pts w hemiparesis/paraparesis to enhance proprioceptive feedback diff methods used 1. changing surface pt sitting (swiss ball) 2. PNF: rhythmic stabilization provided by PT challenges should be progressive and realistic -dual tasking used to challenge a. short sitting b. long sitting (legs extended on mat) compensatory based static sitting required when trunk activation is limited uses tripod/A frame prop sit position: requires arms to be positioned ant or post to hips DONT want arms in line w butt bc pt can fall forward/backward may attempt head righting to maintain position objective: pt remains sitting as they use head righting & UE compensatory mvmnts to put cones on a pole in front of them (video) recovery based dynamic sitting attained by weight shifting 1.WB done w or w/o UE depending on objective 2.WB good for pts that need proprioceptive feedback in UE 3.wt sift away from more involved side (pts w hemiparesis)>>wt shift forward in middle>>wt shift across body toward more paretic side w/in BOS outside BOS -water bottle or plastic cup better for fxnal significance than colored cone remember saliency compensatory based dynamic sitting muscle substitution head righting UE mvmnt - - all to wt shift video: pt using lumbar extensors to right her body vertical summary recovery vs compensatory strategies static sitting -goal is to remain stable -w stand perturbations dynamic sitting -goal is to shift wt w/in or outside BOS 5.10 UE Interventions Lead-up skills Alignment check for proper alignment in the pelvis, trunk, scapula, and proximal UE Stability/mobility Trunk Shoulder Elbows Wrists and Hands After improving alignment, we can work towards improving gross movements, fine motor tasks involving prehension, and then manipulation of objects in either a unilateral or bilateral action SCAPULA SCAPULA IS IN IN DEPRESSION ELEVATION PROTRACTION SCAPULA SCAPULA IN ABI RETRACTION IN ADD When scapulohumeral rhythm is maintained, we can then provide functional interventions Challenge gross motor and fine motor bilateral integration patterns for daily life functions Common activities of daily living of what patients may need to learn Gross Motor Donning Doffing clothes Stabilization Feeding Fine Motor Prehension Pinch Bilateral Integration Food Prep Sports Hygiene UE Assessment Any Shoulder Pain ? GH Impairment Trauma? Improper Handling? Poor Positioning Immobility Learned- Non use Atrophy UE Weightbearing Allows for extremity to be used this predisposing fnctional movmement 2 types of weightbearing Forearm forearm and hand are supported on a surface to bear weight. Can be done sitting or modified standing position Flaccid or spastic arm for proper neutral alignment Can improve proprioception creating approximation Excellent to allow weightbearing with neutral posture and decrease GH subluxation while also activating prox and dist UE muscles Allows for more prox scapular stabilization and mobility as the trunk moves with weight shifting Extended Arm more challenging. Needs activation of muscles of the elbow wrist and hand thereby promoting increased UE stability by means of proprioceptive feedback A required position for bed mobility and functional transfers This also encourages thoracic extension and scapular stabilization 3 positions for EXTENDED ARM Anterior to hips- promotes increased weight bearing to UE to promote a variety of movements without relying on trunk stability In Line with hips- requires more trunk control and is more neutral positions Posterior to hips- requires increased structural stability of the GH joint. THis is the most difficult position of the 3. Clinician may need to avoid subluxation if patient presents with hypotonia by stabilizing the GH joint. Triceps may also be pressed downward and inward to extension of the elbow. Do not lock out their elbow, as patients need to rely on the muscles for stability and not by stacking the bony structures and ligaments. If patient can’t extend arm, then locking out may be needed for compensatory purpose Gentle mobilization may need to be done to avoid impingement of carpal bones to preserve the arches of the hand Weightbearing sequencing 1st sequence usually initiated towards less involved non paretic side. Closed chained weight shifting approach with affected side being stabilized for dynamic movement. Like reaching 2nd sequence simultaneous movement of both arm and the body affected arm is being assisted with the uninvolved arm. 3rd sequence. Most Challenging arm movement with a stable body. Open chained activities. Wiping the table movement. Active participation and control of UE.