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141 Cards in this Set
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Athetosis
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Involuntary movements of moderate speed
Often alternating continuously between two antagonistic movements Often including a rotatory component Typically accompanied by postural instability and fluctuating tone Usually worse in upper body than lower body Occurs in approximately 10% of patients with cerebral palsy |
Athetosis: [Greek = "without fixed position"] Term coined by Hammond (1871) to describe a state of continual motion (of hand, limb, etc.), often slow and writhing
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Dyskinesia
usually caused by: |
involuntary movement disorders (extraneous involuntary movments)
patholgy of basal ganglia |
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Name 4 common types of dyskinesia for PT
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1. athetosis
2. ballismus 3. chorea 4. dystonia |
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PT interventions for athetosis
negatives... |
1. Biofeedback
2. EMG 3. decreased degree of freedom carryover not tested |
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Ballismus =
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Sudden onset, large amplitude, high speed movement
Usually more proximal limb muscles or axial muscles |
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Interventions for Ballismus
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1. meds: haloperidol, pimozide, or sulpiride
2. thalamotomy or thalamic stimulation may be used. 3. holding something in hand 4. focus attention to relax extremeties |
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Chorea =
are choreaform movements correltaed with a loss of function? |
Relatively small amplitude, jerky, involuntary movements
not a strong one. |
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Other causes of _____ are: Other causes are Sydenham’s ___, , vascular accidents, tumors or systemic lupus erythematosus.
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chorea
and fyi- Vascular accidents are the most frequent cause of geriatric chorea, but chorea as a result of a stroke is rare, occurring in only 0.4% of strokes |
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Most common acquired chorea in children
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Syndenhams Chorea
Onset usually between ages 5 and 15 years Symptoms usually last several months 1/3 of these patients also develop rheumatic heart disease 20% to 60% have recurrent episodes of chorea, may be triggered by another infection or other environmental stimulus, pregnancy or oral bcp's |
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which type of invol movement disorder can smuggel their movements?
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chorea
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Chorea med side effects:
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Side effects of the medications are depression, drowsiness and Parkinson-like motor symptoms often more debilitating than the chorea
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How does GABA work
So deficiency of GABA presents with... |
g-Aminobutyric acid (GABA) from the basal ganglia usually refines corticospinal tract activation through inhibition
Deficiency of GABA (eg, in Huntington disease) causes jerky, extraneous movements |
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_________ ordinarily has an inhibitory influence on the basal ganglia
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Dopamine
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Parkinson disease, there is inadequate _________ , so that the acetylcholine stimulates the basal ganglia and increases the inhibitory output to the corticospinal tracts, producing the bradykinesia, rigidity, and other symptoms of PD.
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dopamine
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Define and Describe Huntingtons Disease
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Degenerative disease of CNS inherited as autosomal dominant trait.
Symptoms include cognitive deficits, motor impairments, and behavioral changes Disease becomes apparent usually after age 30 and progresses over roughly 15 years. Death usually caused by respiratory infection |
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Describe progression of Motor Symptoms of HD
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Initial symptoms: excess fidgeting, facial grimacing and apparent nervousness.
As disease progresses, pt complains of incoordination, clumsiness or jerkiness Speech and swallowing often become difficult. Most patients have some dystonia, which is worse among patients taking antidopaminergic drugs and in patients who have had HD longer (Louis 1999). In later stages of the disease, there is less chorea and more dystonia, rigidity and akinesia. |
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Pts with mild to moderate HD have progressive impairments in ....
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of attention, executive functions and working memory, and any timed cognitive test. (Ho 2003)
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describe behavioral progression in HD
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Irritability and aggression tends to occur in early stages, followed by depression, mania and psychosis in the middle stages, followed by apathy in the late stages
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in HD, _____ tends to correlate with severity of cognitive deficits
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Apathy
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HD brain
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showing cortical degeneration contributing to cognitive changes
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Frequently occuring gait abnormalities in HD
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Imbalance
Lateral sway Wide based stance Loss of associated arm swing Difficulty turning Variable walking speed Other abnormalities included: Festination Retropulsion Squatting |
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Are gait abnormalities in HD directly related to chorea?
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Haloperidol substantially decreased chorea but did not affect gait: therefore gait abnormalities not directly caused by chorea
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Name one way to enhance gait and one way that doesnt help for HD
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good one way- metronome
one bad way- Pts with HD did not entrain as well to music. Maybe because cognitive deficits make it hard for them to pick out the beat from complex auditory stimulus of music. |
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results of intensive HD IP program
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Significant improvement in physical performance and Tinetti at discharge. Back to baseline by next readmission – no decline at end of 2 yrs.
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End all suggestion for PT and HD-v
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Concluded there was insufficient evidence to make recommendations about the effectiveness of PT, OT or speech therapy for patients with HD
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Prioirities for Pre/early stages for HD
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Optimize fitness
Teach relaxation techniques Falls prevention (balance training) Home modification (for physical & cognitive deficits) Patient and family education |
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Priorities for Middle and Late stages of HD
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Middle stages:
Remediate impairments (contractures, weakness) Optimize function (balance, gait, ADL’s) Late stages: Pulmonary PT Positioning |
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Dystonia=
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Relatively slow involuntary movements with a sustained contraction at the end
If contraction is sustained for a long time, called dystonic posturing. Usually movement includes rotational component: torsion dystonia |
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Most commen type of dystonia
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Idiopathic Generalized Dystonia (genetic
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idiopathic VS iatrogenic
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Idiopathic refers to a condition for which there is no known reason currently. Iatrogenic means that a condition was caused due to some sort of medical intervention
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idiopathic VS iatrogenic
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Idiopathic refers to a condition for which there is no known reason currently. Iatrogenic means that a condition was caused due to some sort of medical intervention
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Other Causes of Dystonia
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Other causes are Wilson’s Disease (problem with copper metabolism), TBI, vascular problems or tumors affecting basal ganglia, trauma or overuse syndromes
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Sensory Trick / Geste Antagonistique is associated with...
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70% of pts find that tactile input in a certain location will temporarily relax the focal dystonia
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List some associated deficits with dystonia
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Co-contraction & overflow of muscle activation
Decreased reciprocal inhibition Lack of cortical inhibition Evidence of defective motor preparation Evidence for abnormalities of sensory processing: Somatosensory receptive fields abnormally large and disorganized Impaired sensory discrimination Impaired modulation of sensory processing in response to movement Abnormally enhanced CNS plasticity |
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idiopathic generalized dystonia
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Dystonia Musculorum Deformans aka....
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Idiopathic Generalized Dystonia
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Idiopathic Generalized Dystonia =
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Hereditary disorder, usually begins in childhood or adolescence & gets progressively worse, often leading to permanent deformity
Sometimes stabilizes after a few yrs, especially if symptoms don’t emerge until adulthood No intellectual, cerebellar, or pyramidal deficits Evaluation tools available include the Fahn-Marsden Scale and the Unified Dystonia Rating Scale |
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Medical interventions for Idiopathic generalized dystonia
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Some pts get relief from anticholinergic or dopaminergic drugs or baclofen
Some get relief from thalamotomy or pallidotomy or deep brain stimulation Botox injections my be used for key muscles |
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PT Interventions for Idiopathic Generalize Dystonia
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Optimize function by recommending effective strategies and appropriate assistive technology
MAFOs found effective for reducing equinovarus and improving ambulation (McGuire TJ 1988; Hurvitz EA 1988; Mirlicourtois S, 2009) Prevent secondary impairments (e.g., loss of PROM, deconditioning, decreased respiratory function) Teach techniques to reduce dystonia, such as relaxation or in some cases tactile input |
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Autosome =
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An autosome is a chromosome that is not a sex chromosome (22 paris)
In the simplest case, the phenotypic effect of one allele completely ‘masks’ the other in heterozygous combination: that is, the phenotype produced by the two alleles in heterozygous combination is identical with that produced by one of the two homozygous genotypes. The allele that masks the other is said to be dominant to the latter, and the alternative allele is said to be recessive to the former. |
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Autosome =
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An autosome is a chromosome that is not a sex chromosome (22 paris)
In the simplest case, the phenotypic effect of one allele completely ‘masks’ the other in heterozygous combination: that is, the phenotype produced by the two alleles in heterozygous combination is identical with that produced by one of the two homozygous genotypes. The allele that masks the other is said to be dominant to the latter, and the alternative allele is said to be recessive to the former. |
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Neuromuscular Pattern 1 =
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Impaired arousal, ROM and motor control associated with coma, near coma, or vegetative state
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_______ = Impaired motor function and sensory integrity associated with nonprogressive disorders of the CNS acquired in adolescence or adulthood.
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neuromuscualr pattern D
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Axonal Shearing =
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trauma causes twisting and tearing- permanant death of brain cell
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Normal ICP =
Inserted where? |
< 15
Should be monitored closely if ICP > 20 mm Hg ICP of 40 mm Hg limits blood flow, therefore can cause neurological dysfunction: medical emergency! Inserted to different levels Arachnoid Intraventricular Subdural Epidural |
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Cerebral Profusion Pressure =
What does head elevation do to MAP? |
Cerebral Perfusion Pressure (CPP) is the difference between Mean Arterial Blood Pressure (MAP or ABP) and Intracranial Pressure (ICP).
Keep the CPP above 60 mmHg (Robertson CS, 2001). Normal CPP is 80 – 100 mmHg. Elevating the head decreases ICP but also decreases MAP which may result in inadequate cerebral perfusion. Head position between 0o and 30o generally maximizes cerebral perfusion, but individuals vary. (Sullivan J, 2000) |
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Medical TX of inc ICP or bad CPP ?
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using patient positioning
draining cerebral spinal fluid (Ventriculostomy allows monitoring & periodic draining of fluid) administering osmotic diuretics (Mannitol) using vasopressors (constrict arteries & increase BP) inducing coma with barbiturates (reduce metabolic rate of brain tissue & cerebral blood flow, causing blood vessels in brain to narrow, decreasing swelling) evacuating intracranial masses performing decompressive craniectomy. |
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ICP precautions for PT
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Patients with high ICP may be required to keep head of bed elevated to 30o.
Changes in neck position may increase ICP, especially extremes of rotations or flexion because they may restrict blood flow away from the brain by constricting the internal jugular vein. (Shalit MN, 1977) PROM of limbs does not increase ICP, but isometric contractions can increase ICP (Brimioulle S 1997; Koch SM 1996) If your patient has unstable ICP, you should be watching the monitor to determine if what you are doing to the patient is increasing the ICP |
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___________ = An unarousable, unresponsive state, regardless of duration, in which eyes are continuously closed.
Not obeying commands, not uttering words, not opening eyes |
COMA
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________ = Spontaneous eye opening and sleep/wake cycles
No cortical function, but there may be brain stem reflexes |
VEGE
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What do you assess on the glascow coma scale?
What score means good rec prognosis? |
eye response
motor verbal 87% good with 11-15 |
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Mod Recovery issued by GCS literally means =
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Moderate recovery means able to live independently, but unable to go to work or school.
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Good prognostic indicators of COMA
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High GCS scores over the first few days
Short duration of coma Fast rate of recovery observed Less extensive neuropathology (based on MRI) Short duration of post-traumatic amnesia Young Age No history of drug abuse or previous TBI High educational achievement & stable work history Receiving rehabilitation (Aronow, 1987) |
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precautions for endotrahceal tubes-
If patient has a tracheostomy- |
If the endotracheal tube is oral or nasal:
avoid neck movement because it can: dislodge the tube irritate the trachea If patient has a tracheostomy may rotate neck freely moderate flexion and extension allowed |
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feeding tube precautions-
Peg and J - |
While patient is being fed by nasogastric tube and for 20 minutes afterwards
keep head elevated 30o to prevent regurgitation and aspiration PEG and J tube No risk of aspiration, no need to elevate head Be careful when repositioning patient so the tube does not get pulled out |
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CVP monitors =
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Monitors venous pressure and enables administration of fluids
Could be placed in jugular, subclavian or axillary area, and sutured in place. |
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what do you think if CVP is in jugular?
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When in jugular vein,
monitor insertion site during neck movement. Check the protocol in your facility - neck movement may be contra-indicated |
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What do you think if CVP is in subclav?
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Watch closely to avoid pulling out tube at subclavian site when mobilizing the scapula or abducting or flexing the shoulder.
In some facilities, shoulder movement above 90o is contra-indicated. |
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what do you think if CVP is put in axillary?
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Watch closely to avoid pulling out tube at axillary site when abducting or flexing shoulder
Shoulder movement above 90o may be contra-indicated |
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What has precautions more strick then a CVP?
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Pulmonary Artery Lines (PA)
(AKA Swan-Ganz catheters) monitor myocardial function Can be inserted in jugular, subclavian or axillary vein. Because it threads through the heart, precautions may be stricter than those for CVP lines. |
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What monitors myocardial function?
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Pulmonary Artery Lines (PA)
(AKA Swan-Ganz catheters) monitor myocardial function |
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In the ICU, the patient’s _____ is a critical coordinator of care.
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NURSE
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Whats a good measurement of cognition for a patient with nueropattern 1?
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GCS
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what do you think about sensory stim for coma arrousal?
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Cochrane Review (Lombardi 2009) reports that there is inadequate evidence to either support or reject idea of sensory stimulation for coma arousal.
Sensory stimulation for coma arousal is not included as an intervention in the Guide to Physical Therapist Practice. |
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Interventions for prevent pulmonary complications in coma patients
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Relax increased tone around thoracic area
Mobilize rib cage Stimulate diaphragm Reposition for postural drainage Percuss and/or vibrate (mind precautions) Stimulate reflex cough (tracheal tickle) Suction secretions Prevent positioning in neck extension (neck extension can cause aspiration pneumonia) |
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Prevention of integ issues for coma patients-
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Work with nursing staff to identify 2 or 3 positions that will minimize integumentary compromise given this patient’s neuromusculoskeletal status and within constraints of medical precautions.
Provide pictures, training, positioning devices, and physical assistance as needed to facilitate regular repositioning of patient. |
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To prevent typical posturing of UE, position with ...
To prevent typical posturing of LE’s in ..... |
protraction of scapula, abduction of shoulder, extension of the elbow, and finger extension.
extension and adduction, and to stabilize patient in sidelying, use 2 pillows to abduct the hips to enable patient to maintain hip and knee flexion |
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With feet supported by a foot board, the bed can be tilted so that the patient is getting partial weightbearing through the LE’s, which ......
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facilitates co-contraction and may stretch plantarflexors
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20% of patients with moderate to severe BI have _____ during the 1st 14 days after admission to intensive care
so what should you do? |
a seizure and 17% of patients with BI have a seizure during rehab .
Make sure pt can breathe (loosen clothes around neck, make sure no clothes, pillows etc. are around the nose or mouth) Protect from injury, but do not restrain: clear area of sharp objects or anything that could cause an injury, protect head from being bumped. Do not put anything in person’s mouth Notify pt’s physician as soon as possible (STAT page). Call emergency if: Pt having difficulty breathing Pt injures himself Seizure lasts 5 minutes or second seizure follows immediately |
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a 9-15 on GCS correlated to what on Ranchos?
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III to VI
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What scale is more useful to PT when pt comes out of COMA and why?
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Rancho scale more useful for PT’s than GCS after patients emerge from coma because it describes cognitive and learning behaviors
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What is cognitive deficit
Limiting Function of ranchos Level 1 ? |
(no response)
arrousal |
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What is cognitive deficit
Limiting Function of ranchos Level 2 ? |
(generalized response)
awareness of environment |
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What is cognitive deficit
Limiting Function of ranchos Level 3 ? |
(localized response)
consistency of awareness |
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What is cognitive deficit
Limiting Function of ranchos Level 4 ? |
(confused agitated)
filtering and attention |
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What is cognitive deficit
Limiting Function of ranchos Level 5 ? |
(confused inapp)
attention |
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What is cognitive deficit
Limiting Function of ranchos Level 6 ? |
(confused app)
Memory |
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What is cognitive deficit
Limiting Function of ranchos Level 7 ? |
(auto app)
executive functions |
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What is cognitive deficit
Limiting Function of ranchos Level 8 ? |
(purposeful and app)
abstract thinking |
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When do you use Ranchos Scale?
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Use for acute disorders causing dysfunction throughout the brain:
TBI with diffuse axonal shearing Anoxia or CNS due to drowning or heart attack |
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When do you NOT use Ranchos Scale?
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Do not use for pathology causing localized damage:
Stroke Brain tumor MS PD |
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How do you treat a patient with Ranchos Level 1
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Pt appears to be in a deep sleep and is completely unresponsive to any stimuli
Neuromuscular Pattern I (see first BI lecture) |
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________ Rancho Level = Reacts inconsistently and non-purposefully to stimuli.
Responses are limited and nonspecific to stimulus. Responses may be just physiological change, increased or decreased movement, or vocalization this level means that pt has.... |
2 (generalized response)
Patient now has an adequate state of arousal to receive information from the environment. |
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_____ rancho level = Reacts specifically but inconsistently to stimuli. Responses are related to stimuli – e.g., may turn head toward sound, or track moving object. May obey simple commands, but responses are delayed and inconsistent.
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3 localized response
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_______ definiton= Spontaneous eye opening and sleep/wake cycles
Inconsistent but reproducible evidence of awareness of self or environment |
minimally con. state
20% with severe TBI are unresponsive at least 1 month and may go through period of inconsistent awareness Individualized Quantitative Assessments can be used to identify evidence of awareness |
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Modest Goals when TBI prog is poor-
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Even if pt’s prognosis is severe disability, there are mobility goals that will improve quality of life for pt and caregiver.
Developing a communication system is a priority. Being able to control eye and head movement to orient towards stimuli of interest can make a substantial difference for a pt who will live the rest of his life as primarily an observer. Ability to orient towards caregiver and provide any physical response to caregiver input creates a bond that improves quality of life for pt and caregiver. |
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_____ rancho level =
In heightened state of activity. Behavior is bizarre and non-purposeful relative to immediate environment. Doesn’t discriminate among persons or objects. Unable to cooperate with treatment efforts. Verbalizations frequently incoherent or inappropriate to context. Gross attention is very brief, lacks selective attention. Lacks short or long-term memory |
4 confused agitated
Pt will not cooperate with traditional exam. You must observe patient’s spontaneous activity to assess neuromusculoskeletal status |
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In _____ agitation is believed to be caused by chaos of the CNS:
Previously established neural connections have been disconnected by the injury. There is increased random firing of neurons due to the increased sensitivity of denervated neurons. Pt may appear to _______ |
level IV
be hallucinating. Agitation seems inappropriate to circumstances, although placing demands on patient may increase his confusion and therefore increase his agitation. |
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Post traumatic agitation is assoc with....
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Occurs in 30% (Bogner JA, 1995) to 50% (Kadyan V, 2004) of people with TBI
Duration of agitated period (Kadyan V, 2004) Mean number of days of agitation = 16 Median number of days of agitation = 9 Occurrence of agitation during rehab was associated with: Poorer cognition at admission and discharge Increased length of stay in rehab Decreased likelihood of discharge to private residence (Bogner JA, 1995) Pharmacological interventions (sedatives) for agitation decrease cognitive function, potentially resulting in rebound agitation and worse prognosis (Mysiw WJ, 1997) |
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ABS (agiated behavioral scale) results mean....
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For clinical purposes:
21 or below: within normal limits 22 - 28: mild agitation (range is from 14-56) 29 – 35: moderate agitation >35: severe agitation |
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______ rancho level =
Responds to simple commands fairly consistently. With increased complexity of commands or lack of external structure responses are non-purposeful and fragmented. Pays gross attention to environment, but highly distractible, lacks ability to selectively attend to specific task. Memory severely impaired. May show inappropriate use of objects May perform previously learned tasks with structure, but unable to learn new information. |
5, confused inap
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______ rancho level = First level of cognitive function at which patient with TBI can fairly consistently follow simple commands, so you can perform simple components of a traditional neuromusculoskeletal examination
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5 confused inap
Cognitive Assessment primarily documentation of circumstances in which patient can or cannot attend to an activity. |
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without attention there can be no...
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further information processing
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What type of attention requires:
Arousal - awakeness Vigilance – maintenance of a state of alertness or readiness to respond to changes in environment |
sustained
Document how long pt can continue to be engaged in an activity |
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____ = Ability to focus on a task while screening out distractions. AKA _______
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A person lacking selective attention is said to be “distractible
Document what types of activities the pt can selectively attend to and what types of stimuli (e.g., visual, auditory, tactile) the pt can or cannot screen out |
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______ = Ability to move flexibly between tasks without agitation or perseveration on first activity
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alternating attention
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____ = Ability to simultaneously attend to more than one task
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divided attention
Document whether your patient can persist at a fairly automatic activity while engaged in a new activity |
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Level ______ (rancho) = For example, a pt may continue to get agitated disproportionately to the circumstances and yet start to demonstrate attention to the environment.
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4 + 5
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List some level 5 (rancho) interventions to prevent physical impairements
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Elicit movement on an automatic level with minimal verbal cues. (e.g., equilibrium and protective reactions)
Provide physical guidance or assistance as needed to enable the pt to perform the desired movements. Use regulatory features of the environment to encourage the desired movement. |
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what does research say about attention interventions?
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There is inadequate evidence to say whether or not attentional training is helpful in acute rehab with patients with moderate to severe TBI. While these patients may improve over time, there are not adequately controlled studies to differentiate spontaneous recovery from effects of intervention.
There is good evidence that attentional training, with emphasis on development of strategies to compensate for residual deficits, is effective in the post-acute phase of rehabilitation. |
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_______= Widely used strategy for remediating attentional deficit of people with BI
Hierarchically organized tasks to practice sustained, selective, alternating and divided attention. Examples: listening for descending number sequences on an auditory tape, alphabetizing words presented orally, etc. Sohlberg (2000) reported improved performance on attention tests for people with chronic BI after APT compared to control condition |
Attention Process Training (APT)
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List interventions for sustained attention and then for selective attention
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Sustained attention: Identify activities that are interesting / motivating to the pt and provide opportunities to engage in these activities without distractions. E.g., if premorbidly pt was interested in football, either talk about, look at pictures of, or act out parts of football games in a quiet room.
Selective attention: Initially eliminate any possible distractors. Gradually fade in distractors so that the pt accommodates to them instead of reorienting attention towards them. E.g., start in quiet room. Gradually increase volume of radio talk show |
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List interventions for alternating attention and then for dividing attention
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Alternating attention: Initially switch from less interesting to more interesting activities to ease alternation. (E.g. Start with leg exercise, then transition to tossing a football.) Then work on switching between equally interesting activities (e.g., tossing a football to shooting baskets.)
Divided attention: Identify task that pt can perform easily, automatically, then add in another easy task. If pt is able to move bean bags from his right side to his left side easily, or ride a stationary bike easily, ask him to keep doing it while you ask him simple questions. Gradually increase difficulty of tasks. |
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____ rancho level =
Pt shows goal-directed behavior, but is dependent on external cues for direction. Follows simple directions consistently Demonstrates carry-over for relearned tasks Little or no carry-over for new tasks Responses may be incorrect due to poor memory, but will be appropriate Better remote memory than recent memory |
6
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Post traumatic amnesia (PTA) refers to period after BI when
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anterograde memory is severely impaired.
Anterograde amnesia: difficulty encoding or storing new memories |
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Retrograde amnesia =
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inability to access information that was stored in memory prior to the injury
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DeLuca J (2000) suggests that for pts with moderate to severe TBI, memory problems that persist after discharge from rehab are primarily problems with
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acquisition, not retrieval (i.e. anterograde not retrograde)
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Intervention for Anterograde Memory Dysfunction
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Remember the problem is in storing the memory, not in retrieving it.
Your intervention should occur at time of storage, not at time of retrieval. Interventions: facilitate mental storage teach compensatory strategies |
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Mnemonic Strategies for Facilitating Storage of New Memories
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Associate with a strong emotion (fear, delight)
Immediate rehearsal (mental or oral) Visual imagery (Kaschel R, 2002, in RCT demonstrated effectiveness for pts with mild memory impairment secondary to BI) Verbal cues, e.g. ROY G BIV or On Old Olympus Towering Tops, A Finn And German Viewed Some Hops, or Some Lovers Try Positions That They Cannot Handle (Bones of the wrist ) Mentally interconnecting with related ideas already known Connect to something emotionally meaningful to the pt (name of relative or favorite character) |
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______ lobe is your brain’s filing system.
With an organized filing system with extensive cross-referencing, it is easier to retrieve information |
frontal
Recognition memory better than recall- Associated with frontal lobe lesions |
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Interventions for Memory Retrieval
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Facilitate retrieval at time of storage by:
creating conceptual maps of how information is interrelated by creating associations between new information and old information. The more such cross-references we have, the easier the retrieval. (Compare to computer data bases) |
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There is evidence that teaching remediation strategies to improve memory is effective for patients who are
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fairly independent in daily function and are motivated to work on improving their memory.
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For patients with severely impaired memory, there is strong evidence that remediation strategies are
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not effective. It is recommended that intervention focus on learning the specific skills of interest rather than working on memory skills in general.
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There is strong evidence that compensatory strategies are effective for people with memory deficits mild enough that
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they are able to remember how to use the strategies.
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____ = Memory of a plan to do something at some later point in time
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Prospective Memory
remembering to make a phone call when you get home from school remembering to turn off the stove when the food is cooked remembering to turn off the water after the bath is adequately filled |
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Intervention for Prospective Memory Problems
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Difficult because of temporal component.
For regular events, may be able to train as a habit. For irregular events, need an orientation to monitoring time at regular intervals and perhaps using a schedule book or check list May require use of timed alerting device: alarm clock, timer, beeper, pager. |
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Two types of declarative memory
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(Memory of facts that can be stated (declared) in words) (explicit)
Semantic memory: memory of facts Episodic memory: memory of experiences |
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_______ = Memory of how to do something such as riding a bike or speaking one’s native language with appropriate grammar
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Procedural Memory
Implicit: we are not consciously aware of the procedure we have learned |
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implicit memory =
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we are not consciously aware of the procedure we have learned
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Standardized tests of memory typically measure____ memory, not ______ memory
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declarative
procedural |
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Can Level V & VI Patients Learn
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Patients can have impaired declarative memory without having impaired procedural memory. A pt may not remember having been to PT before, and yet with multiple practice trials of a motor skill, the pt.’s performance of the motor skill may improve
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Patients with posttraumatic amnesia have demonstrated ability to learn ......
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procedural tasks
Procedural memory occurs through repetition which strengthens synaptic connections. The pt’s response will be based on the strongest synaptic connections |
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Video of hand-over-hand physical guidance with backward chaining to wean patient off of guidance
this is an example of? |
errorless learning
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_____ rancho level =
Appears appropriate and oriented within hospital and home Performs daily routines automatically Shows carryover for new learning but at decreased rate With structure able to initiate social or recreational activities Executive functions impaired |
7 auto-appt
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Functions Frontal Lobe =
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Formulating goals
Developing plans / Organizing tasks Initiation and follow-through Monitoring performance and outcomes Insight and Judgment Problem solving |
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Executive functions are required for engaging in any ...
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non-routine activity
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When a person is required to perform a task that is different from the routine, he must have ....
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insight into his own abilities, be able to predict the outcome of his behavior, and be able to monitor his actual performance and the actual outcome of his behavior (Kennedy MRT, 2005)
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Individuals in the acute recovery phase after TBI are less accurate at ...
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assessing their abilities than their therapists are. Educate patients with BI about the accuracy or inaccuracy of their self-perception, and provide feedback to help them develop accurate self-perception
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Being in a hospital for an extended period of time tends to create a learned ....
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dys-executive syndrome. Patients get used to doing what they are told.
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Initiation and Follow-through...
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As part of the plan for an exercise program, agree that the pt will initiate the program as soon as he is brought to PT for the next session, and will carry out the entire program without any input from you.
You should plan to be within sight, but busy with another patient. If he is not doing it, wait 5 to 10 minutes if still not doing it, ask him what he is suppose to be doing today |
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Monitoring performance and outcomes........
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After pt has completed an activity, ask him how it went.
If he is vague, ask him specifically, did he achieve what he wanted to achieve and if not, what went wrong. If he is inaccurate in his assessment, tell him how your assessment differs from his. If he rejects your assessment, use an objective measure (videotape or standardized assessment tool such as Berg) next time |
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____ = refers to awareness of one’s own limitations
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insight.
ask the pt if he thinks he is able to get off the exercise bicycle safely by himself |
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___ = refers to ability to choose a course of action that will have a positive outcome
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Judgment
In the Neurobehavioral Cognitive Status Examination (NCSE) judgment is evaluated by asking questions beginning with “What would you do if…” |
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Two systematic literature reviews concluded that formal training in problem-solving skills for people with TBI ....
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is effective in improving problem solving skills
E.g., teaching patients to explicitly identify problems, formulate solutions, identify pros and cons of solutions, and self-check implemented solutions for a series of problems Do not intervene unless: Pt is unsafe Pt has stopped paying attention to the task Pt is getting frustrated |
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Levels of Cueing to Facilitate Problem Solving, Start with indirect cues such as...
If indirect cues are inadequate, give more direct cues, such as... |
Think before you do anything.”
“Are you forgetting anything?” “What is the problem?” “Is something blocking your cane?” “Is that stool causing problems?” Only provide the solution after pt has tried. Sometimes pt needs a different perspective from which to view the problem. You can provide this by acting out the problem or videotaping the pt when he is stuck. If pt still can’t identify the problem, you can act it out in a way that exaggerates, or calls attention to the problem |
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Role of PT in Development of Patient’s Social Skills
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Model desired behaviors when interacting with pt.
Provide feedback to pt regarding pt’s behavior Assist patient in recognizing the meaning of facial expressions, tone of voice, and body language Teach skills such as eye contact, body position, appropriate verbal phrases for specific situations Provide positive reinforcement to encourage desired behaviors. |
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_____ rancho level =
Shows carryover for new learning Needs no supervision once activities are learned May continue to show decreased: abstract reasoning & creativity tolerance for stress judgment in unusual circumstances |
Level VIII:
Purposeful and Appropriate |
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_____ = Inability to think abstractly, Inability to generalize from the similarities between situations
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Concrete Thinking
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______ = helps pts carry-over general concepts learned in one context to another context.
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Abstract reasoning
We can encourage abstract reasoning by identifying for our pts abstract principles, and asking pt to apply to new contexts. E.g. teach pt concept of large base of support. During a variety of activities, challenge the pt to enlarge or narrow the BOS and tell you whether he feels more stable or less stable. |
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Heterotopic Ossification =
Most common in - Risk factors include- |
Abnormal bone growth around a joint
Occurs in 10% to 20% of people with TBI (Garland DE, 1991) Most common in hip, shoulder, knee and elbow Risk factors include: Trauma Immobility/paralysis/paresis (Tsur A, 1996) Spasticity (Tsur A, 1996) |
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Heterotopic Ossification Commonly detected when?
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Commonly detected 2 months post injury when patient feels pain, there is loss of ROM, and joint feels warm to touch
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