Therapy Ed Chapter 12- Neurological Approaches

Front 1

General principles of contemporary task-oriented approaches to motor control training

Back 1

-reject assumptions of the reflex-hierarchical model
-remediation of client factors and environmental modifications to improve task performance
-based on a systems model of motor control (motor control is determined by interactive systems, behavioral tasks, and adaptive mechanisms
-movement controlled by integration of multiple systems
-control is not simply over mm actions, but over interactions of kinematic variables

Front 2

Principles of Carr and Shepherd's Motor Relearning Program (MRP)

Back 2

-person is an active participant whose goal is to relearn effective strategies for performing functional movement
-postural adjustments and limb movements are linked together
-successful task relearning has occurred when tasks are perform automatically and efficiently
-learning of skills does not follow a developmental sequence
*continued practice of compensatory strategies limits recovery
-intervention focused on learning general strategies for solving motor problems, not on specific movements
-obstacles to mvmt include loss of soft tissue extensability, balance, postural insecurity and mm weakness
*abnormal mvmt patterns attributed to repeated practice of overlearned compensatory strategies

Front 3

Principles of the Contemporary Task-oriented approach

Back 3

-occupational performance emerges from interaction of multiple systems including personal and performance contexts
-systems (including CNS) are organized
-behavior changes reflect pt's attempt to compensate and achieve functional goals
-pt's must practice with varied strategies to find optimal solutions for motor problems
-functional tasks help organize motor behavior
-therapist must decide which control parameters influence motor behavior
-provide practice appropriate to pt's stage of learning
-top-down approach used
-eval focused on role performance

Front 4

Focus of interventions in the contemporary task-oriented approach

Back 4

1. helping pt adjust to role and limitations
2. create environment that utilizes common challenges of everyday life
3. practice functional tasks to find efficient strategies
4. provide opportunity for practice outside of therapy
5. remediating a client factor
6. minimize ineffective movement patterns
7. adapt the environment
8. modify the task
9. use assistive technology

Front 5

Principles of motor learning

Back 5

1. remediating motor control in people w/ CNS problem
2. goal is acquisition of functional skills that can be generalized to multiple situations and environments
3. stages of motor learning
4. practice
5. intrinsic and extrinsic feedback
6. closed, variable motionless, consistent motion, and open tasks

Front 6

Stages of motor learning

Back 6

1. skill acquisition stage(cognitive stage) -occurs during initial instruction and practice of a skill
2. Skill retention stage(associated stage)- involves carry-over
3. skill transfer stage(autonomous stage)- individual demo's skill in a new context

Its an A.R.T.

Front 7

Practice in motor learning

Back 7

1. random- several tasks in a random order
2. blocked - repeated performance of same skill
3. practice of whole task
4. practice of parts of a task
5. variable conditions practice
6. mental practice - cognitive rehearsal w/out actually moving

Front 8

Conditions that promote generalization of motor learning

Back 8

1. capacity to generate intrinsic feedback
2. high feedback regarding knowledge of performance
3. low intrinsic feedback regarding knowledge of results
4. variable practice conditions
5. whole task performance
6. high contextual interference (noisy places)
7. practice where the skill will be utilized

Front 9

Treatment sequence to promote generalization of learning

Back 9

1. initial task is the first activity performed by pt.
2. near transfer- alternate form of initial task
3. intermediate transfer- moderate # of changes in specific task parameters but some similarity to original task
4. far transfer- introduces activity that is conceptually the same but physically different from original
5. very far transfer- spontaneous use of the new strategy in daily functional activities

Front 10

Strategies for each stage. Table p. 259

Back 10

...

Front 11

Motor learning task categories

Back 11

1. closed tasks- environment is stable and predictable, methods of performance are consistent over time
2. variable motionless tasks- stable and predictable environment, but specific features of environment vary between trials
3. consistent motion tasks- require pt to deal w/ environmental conditions in motion during activity performance; motion is consistent and predictable between trials
4. open tasks- require people to make adaptive decisions about unpredictable events b/c objects within environment are in random motion during task performance

Front 12

Neurophysiologic "traditional" "sensorimotor" frames of reference (comparison table p. 260)

Back 12

NDT, PNF, Brunnstrom's, Rood's
-utilized for people with CNS dysfunction
-traditional perspectives from the 40s and 50s

Front 13

General assumptions of Traditional Frames of Reference

Back 13

-controlled movement is preceded by stereotyped reflex responses
-sensation is necessary for movement to take place
-cerebral cortex controls middle levels which in turn controls the spinal cord
-damage to higher control centers release primitive reflexes and movement patterns from inhibition
-skilled mvmt occurs automatically when basic movements are normalized
-controlled sensory input from therapist can influence motor responses
-facilitation and inhibition techniques

Front 14

Neurodevelopmental Treatment (NDT)/ the Bobath Technique

Back 14

-normalization of postural and limb tone (spastic or flaccid) is prerequisite to normal movement
-avoidance of mvmt and activities that increase tone
-inhibit primitive reflexes and abnormal posture and limb movements
-development of normal patterns of posture & mvmt
-improve quality of mvmt and performance of involved side
-associated reactions should be avoided
-postural reactions are considered basis for control of mvmt
-loss of postural control results in overuse of sound side and limits functional movement
-stereotypical patterns of trunk and limbs observed in pts w/ cns issues are viewed as abnormal patterns of motor coordination

Front 15

Focus of NDT/Bobath technique

Back 15

focus is on improving quality of movement
(integration of both sides, ability to weight bear, normal movement patterns, normal righting/equilibrium)

Front 16

Evaluation procedures for Bobath/NDT

Back 16

-observe malalignments in trunk and limbs in various postures
-guide limbs through mvmt patterns to eval tone
-ability to hold a position
-assess for associated reactions/situations that evoke them
-eval postural control
(righting, equilibrium, protective responses, weightshifting)
-abnormal coordination patterns of limbs (timing of mvmts, sequencing, coordination of mm activation)
-autonomic postural reactions & volitional mvmts of trunk & limbs

Front 17

Intervention for Bobath/NDT

Back 17

-handling is the hallmark of NDT. Therapist's hands are utilized to attain intervention goals
-specific handling techniques to promote normal movement**
-key points of control
-inhibition techniques for hypertonicity
-specific techniques to normalize tone
-establish ability to weight shift
-retrain ADL while limiting abnormal response
-bilateral mvmt patterns

Front 18

specific handling techniques to promote normal movement in Bobath/NDT

Back 18

-provide external stability during movement
-normalize movement patterns
-facilitate or inhibit specific mm groups
-inhibit abnormal patterns of control
-provide sensory input
-increase ROM
-dissociate body segments
-normalize tone

Front 19

Proprioceptive Neuromuscular Facilitation (PNF)

Back 19

-utilized for neurologic and orthopedic patients
-normal motor development proceeds in a proximodistal and cervicocaudal direction
-early motor behavior dominated by reflexes
-in development, there are shifts b/t flexor and extensor dominance
-maintaining posture requires continual adjustment
*diagonal patterns

Front 20

PNF eval procedures

Back 20

-proximal to distal
-respiration, swallowing, voice, facial movements
-mvmt in response to stimulation
-observe head and neck patterns during activity
-diagonal patterns of the extremities (bilateral symmetrical, bilateral asymmetrical, bilateral reciprocal, unilateral)
-can they maintain posture
-observe functional task

Front 21

observations made throughout PNF eval

Back 21

-dominance of flexor or extensor tone
-midline alignment
-stability and mobility in various patterns
-influence of head, neck, and trunk patterns
-range of motion
-quality of movement
-timing of movements

Front 22

PNF interventions

Back 22

-patterns chosen in an effort to remediate missing components
-2 pairs of diagonals for each body segment
(D1 flexion, D1 extension, D2 flexion, D2 extension)
**review patterns pg. 263
-flexion or extension is major component
-all patterns cross midline
-combinations are utilized

Front 23

Other techniques used during PNF

Back 23

-therapists hands over agonist to facilitate a response
-quick stretching to elicit a contraction
-traction of joint space to stimulate joint receptors
-manual compression to stimulate joint receptors
-max resistance (amount pt can receive and still move through range)
-repeated contractions of agonist to build endurance
-rhythmic movement
-Relaxation techniques: contract-relax and hold-relax

Front 24

contract-relax vs hold-relax

Back 24

contract-relax is contract, relax, then passive mvmt by therapist.

hold-relax is contract, relax, then active mvmt by patient

Front 25

Brunnstrom's movement therapy

Back 25

*outdated
-focused on facilitating recovery through a specific sequence
-7 stages of motor recovery
(1=flaccid, 2=min mvmt, 3=marked spasticity, 4=mvmt begin to deviate from synergy, 5=mvmts vary, 6=no spasticity, freely perform isolated mm actions, 7=normal)
-intervention focus is to facilitate process

Front 26

Rood's approach

Back 26

*outdated
-treatment begins at pt's developmental level and progresses sequentially
-4 sequential phases of motor control:
reciprocal inhibition, co-contraction, heavy work, skill
-motor response depends on type of stimulation therapist applies

Front 27

Eval procedures in Rood's approach

Back 27

-distribution of mm tone
-determine level of motor control based on Rood's developmental sequence
-determine activity of choice and how to progress to next level of control

Front 28

Intervention for Rood's

Back 28

-normalization of tone and mm response via controlled sensory stimulation
-motor response acheived depends on type of sensory stimuli (facilitation or inhibitory)

Front 29

Facilitation techniques in Rood approach

Back 29

-fast brushing via a battery operated brush
-tendon tapping
-high frequency vibration
-quick icing
-heavy joint compression
-resistance

Front 30

Inhibition techniques in Rood approach

Back 30

-gentle rocking for generalized relaxation response
-slow stroking over posterior rami of spine has a generalized inhibitory effect
-slow rolling from sup to sidelying and back
-tendinous pressure over mm insertion to inhibit specific mm
-maintained stretch to overactive mm group
-neutral warmth (wrapping in a blanket)
-prolonged icing over a mm group

Front 31

Ashworth and Modified Ashworth scales

Back 31

*measure spasticity
-limb quickly stretched in direction opposite the pull of the mm group being tested
-Ashworth: 1=normal, 5=severe rigidity
-Modified Ashworth: 0=no inc. in mm tone, 4=rigid in flex or extension

Front 32

Reflex testing

Back 32

Evals involuntary stereotyped responses to a particular stimulus.

Intensity/quality of response is monitored.

Responses = positive

No Responses = negative

Front 33

Grasp

Back 33

Stimulus: pressure to palm of hand

Response: finger flexion that resists object removal

Front 34

Flexor withdrawal

Back 34

Stimulus: stimuli to sole of foot

Response: flexion of stimulated leg

Front 35

crossed extension reflex

Back 35

-Stimulus: passively flex extended leg while opposite leg is flexed
-response: extension of opposite leg w/ adduction and int rot

Front 36

ATNR

Back 36

-stimulus: rotate head 90 deg
-response: limb ext on face side, flex on skull side

Front 37

Tonic labyrinthe

Back 37

-stimulus: prone position followed by supine position
-response: prone results in flexor posturing of arms/legs. supine results in extensor posturing of arms/legs

Front 38

positive supporting reaction

Back 38

-stimulus: contact to ball of foot in upright position
-response: extension of the legs

Front 39

Equilibrium reactions

Back 39

-Stimulus: displace center of gravity by tipping support surface
-response: righting of head/trunk/limbs

Front 40

Qualitative descriptions of motor control

Back 40

Evals of motor control should include observations of the quality of movement during performance of functional tasks.

Motor control issues resulting in observable poor quality of movement

Front 41

Dysmetria

Back 41

undershooting (hypometria) or overshooting (hypermetria) of a target.

Front 42

intention tremor

Back 42

worsening of action tremor as limb approaches an object

Front 43

dyssynergia

Back 43

breakdown in mvmt resulting in joints being moved separately to reach a desired target as opposed to a smooth trajectory

Front 44

dysdiadokinesia

Back 44

impaired ability to perform rapid alternating movements

Front 45

ataxia

Back 45

loss of motor control including tremors, dysdiadokinesia, dyssynergia, and visual nystagmus

Front 46

resting tremor

Back 46

tremor noted in resting postures

Front 47

rigidity

Back 47

cogwheel- alternative contraction/relaxation of mm being stretched
lead pipe- consistent contraction throughout range

Front 48

Bradykinesia

Back 48

overall slowing of movement patterns

Front 49

akinesia

Back 49

inability to initiate movements

Front 50

athetosis

Back 50

dyskinetic condition that includes inadequate timing, force, and accuracy of movements in trunk/limbs

Front 51

dystonia

Back 51

involuntary sustained distorted mvmt or posture involving contraction of groups of mm

Front 52

chorea

Back 52

involuntary mvmts of face and extremities which are spasmodic and of short duration

Front 53

hemiballismus

Back 53

unilateral chorea characterized by violent, forceful movements of the proximal mm

Front 54

Assessment for glenohumeral joint subluxation

Back 54

-allow person's arm to dangle into gravity
-palpate space underneath acromion process with index finger
-compare to intact side and document width in terms of finger breadth

Front 55

Purposes of Orthoses/Splints

Back 55

Orthoses utilized in pop. w/ neuromuscular dysfxn to meet following goals:

1. prevent/correct deformity via prolonged stretch & proper alignment

2. Control spasticity by aligning joints & providing prolonged stretch to spastic muscles

3. Prevent/decrease/accommodate contractures

4. Position hand in fxn posture to promote engagement

5. compensate for weakness to allow intact muscle groups to fxn

6. provide proximal support

7. support a painful joint

8. promote distal mobility

9. enhance a specific activity

10. immobilize joint & soft tissue to promote healing

11. prevent or reduce scarring via prolonged pressure & appropriate stretch

Front 56

Resting hand splint

Back 56

for people who need to heave wrist, digits, and thumb supported in a functional position for long periods (ie. when developing contractures of long flexors)

Front 57

opponens splint

Back 57

-short or long
-supports thumb in position of abduction and opposition
-utilized during functional activity to compensate for weakness

Front 58

Types of inhibitory/ tone normalizing orthoses

Back 58

-based on neurophysiologic frames of reference
-Bobath finger spreader
-rood cone
-Orthokinetic splints
-Spasticity reduction splint

Front 59

Bobath finger spreader (abduction splint)

Back 59

-based on Bobath's principle of reflex inhibiting patterns
-soft splint positions the digits and thumb in abduction in an effort to reduce tone

Front 60

Rood cone

Back 60

-based on Rood's inhibitory principles of sustained deep pressure
-cone-shaped splint used to reduce flexor spasticity in the hand

Front 61

Orthokinetic splints

Back 61

-utilizes tactile input via elastic bandages to facilitate or inhibit mm groups

Front 62

spasticity reduction splint

Back 62

places the spastic distal extremity on submaximal stretch to reduce spasticity

Front 63

Overhead suspension sling

Back 63

-incorporates an arm support that is supported by a sling and suspended by an overhead rod
-persons presenting with proximal weakness (ALS, Guillan barre, musc dystrophy) w/ mm grades of 1-3/5

Front 64

Balanced forearm orthoses

Back 64

-mobile arm support or ball-bearing forearm orthosis
-consists of arm trough, proximal and distal arms, and a support bracket
-allows a pt w/ weak proximal musculature to utilize trunk and shoulder

Front 65

Splinting considerations

Back 65

-wearing schedule must be prescribed (longer to decrease spasticity or reverse contracture)
-monitor for pressure points (especially over bony surfaces)
-donning/doffing reviewed and documented
-choose appropriate material

Front 66

evaluation of oral motor dysfunction

Back 66

-ROM, strength, tone of lips, cheeks, and tongue
-extra- and intra-oral sensation
-dentition
-oral control of bolus
-presence of a swallow reflex
-mechanisms for airway protection
-relaxation of esophogeal sphincter
-primitive reflexes
-cranial nerve testing
-objective tests (modified barium swallow)

Front 67

Swallow reflex

Back 67

1. laryngeal elevation when the larynx rises to approximate the epiglottis and protect the airway
2. soft-palate elevation when the soft palate rises to close off nasopharynx to prevent food from entering nasal cavity
3. pharyngeal peristalsis

Front 68

Mechanisms of airway protection in swallowing

Back 68

-gag reflex: expels a bolus that is too large from entering pharynx
-volitional and spontaneous cough utilized to clear pharynx of residual material
-vocal folds close off airway
-reflexive inhibition of respiration to prevent food from entering airway

Front 69

Primitive reflexes in oral motor

Back 69

1. rooting- normal response is no reaction. Pathological- turn toward stimulus
2. Jaw jerk- center of mandible firmly tapped 1-2 times. Normal response is no reaction. Pathological is jaw closure/opening.
3. Bite reflex- tongue depressor placed b/t teeth. Reflexive bite indicates pathology.

Front 70

Direct therapy for oral motor dysfuntion

Back 70

*direct therapy involves techniques that utilize a bolus
1. modification of consistency, amt, and placement of food
2. posural interventions: chin tuck, head tilt, head turn
3. specific swallow adaptations:
a) supraglottic swallow technique to protect airway during food intake
b) Mandlesohn's maneuver: voluntary prolonging rise of larynx by prolonging tongue contraction

Front 71

Indirect therapy for oral motor dysfunction

Back 71

*indirect therapy does not utilize a bolus
1. thermal (cold) stimulation to interior faucial arches
2. reflex facilitation
3. strengthening, facilitation, and coordination of oral movements
4. airway adduction procedures
5. positioning to maintain head/neck/trunk in correct postures

Front 72

Motor control inclusion criteria for affected side with CIMT

Back 72

-20 deg ext of wrist and 10 deg ext of each finger OR
-10 deg ext of wrist, 10 deg abd of thumb, and 10 deg ext of any 2 other digits OR
-able to lift a washrag from a table and release it

Front 73

CN I

Back 73

olfactory
-sensory. sense of smell
-ask person to sniff various substances

Front 74

CN II

Back 74

Optic
-sensory, carries impulses for vision
-test via eye chart, visual field testing

Front 75

CN III

Back 75

Oculomotor
-Mixed. motor for eye mvmts, sensory for proprioception of the eye
-compare pupil sizes , pupillary reflex, visual tracking

Front 76

CN IV

Back 76

Trochlear
-Proprioceptor and motor fibers for sup oblique mestm of eye. Downward and inward eye mvmt
-test w/ CN III relative to following moving objects

Front 77

CN V

Back 77

Trigeminal
-Mixed. Motor and sensory for face. Sensory to mouth, nose, eyes. Motor for chewing.
-Test pain, touch, and temp, corneal reflex w/ cotton, move jaw through ROM

Front 78

CN VI

Back 78

Abducens
-motor and proprioception to/from lateral rectus. Lateral eye mvmt
-test in conjunction w/ CN III relative to moving eye laterally

Front 79

CN VII

Back 79

Facial
-mixed. sensory to taste buds, ant 2/3 tongue. Motor to mm of facial expression, salivary gland
-check symmetry of face, ask to attempt facial expression, check taste

Front 80

CN VIII

Back 80

Vestibulocochlear
-sensory. Equilibrium and hearing,
-check hearing w/ tuning fork

Front 81

CN IX

Back 81

Glossopharyngeal.
-motor for pharynx and salivary glands. sensory for pharynx and post tongue. taste
-test gag and swallow reflexes, post 1/3 for taste

Front 82

CN X

Back 82

Vagus.
-mixed for larynx and pharynx. motor to abdominal organs. sensory from viscera
-test w/ CN IX

Front 83

CN XI

Back 83

Spinal accessory.
-mixed for sternocleidomastoid, trap, soft palate, pharynx, larynx. Movement of neck and shoulders.
-Test sternocleidomastoid and trapezius

Front 84

CN XII

Back 84

Hypoglossal.
-mixed from tongue. movement of tongue
-ask to stick out tongue and note positional abnormalities

Front 85

Principles of sensory integration

Back 85

-plasticity of CNS allows for modification of CNS
-sensory integration occurs in a developmental sequential manner
-higher cortical processing dependent on adequate processing or sensory stimuli
-adequate modulation of sensory stimuli must occur for adaptive response to occur. Sensory stimuli can be facilitory or inhibitory
-adaptive responses facilitate integration of sensory stimuli
-individuals seek out experiences that have an organizing effect

Front 86

Sensory Integration and Practice Test (SIPT)

Back 86

*4-8 yrs old
-17 tests to address relationship among tactile processing, vestibular-proprioceptive, visual
-computerized scoring
A. Categorized into 4 overlapping groups:
-tactile and vestibular-proprioceptive sensory processing
-form and space perception and visual-motor coordination
-practic ability
-bilateral integration and sequencing
*requires certification to administer

Front 87

DeGangi-Berk Test of Sensory Integration (TSI)

Back 87

*3-5 yrs old
-focus on vestibular system
-3 areas: bilateral motor coordination, postural control, reflex integration

Front 88

Test of sensory function in infants

Back 88

*1-18 months of age
-assesses level of infant's sensory responsiveness to variety of stimuli

Front 89

Sensory processing measure (SPM)

Back 89

*elementary school age children
- measures sensory processing, praxis, and social participation across different environments
-assesses visual, auditory, tactile, olfactory-gustatory, proprioceptive, and vestibular behaviors
-home form completed by caregiver or classroom form completed by teacher

Front 90

General intervention for sensory processing disorders

Back 90

-facilitate sensory integration
-create an environment to facilitate active participation
-ensure registration of meaningful sensory input
-balance structure and freedom
-gradually introduce activities
-promote organized adaptive response to enhance behavioral organization

Front 91

intervention for tactile defensiveness; hyper or hypo-sensitivity; sensory seeking

Back 91

-self-applied stimuli more tolerable than passive
-firm pressure where child can see source
-controlled sensory activities that simultaneously provide tactile and vestibular-proprioceptive input
-begin with slow linear movement and deep touch
-apply stimuli in direction of hair growth
-follow tactile stimuli with joint compression
-monitor and adjust lighting, etc
-be alert to behavioral responses
-tactile-defensiveness and sensory-seeking can be reduced if treatment is effective

Front 92

Intervention for tactile discrimination

Back 92

-deep touch pressure to hands and body
-deficits rarely seen in isolation, usually need tx for motor planning
-graded activities using a mixture of textures and items

Front 93

Intervention for proprioception under, over-responsivity and sensory seeking

Back 93

-firm touch, pressure, joint compression, traction
-resistance to active mvmt to help child learn appropriate amount of force to complete a task
-activities in various body positions (yoga)
-slow linear movement, resistance, and deep pressure
-adaptive techniques (weighted vest)

Front 94

intervention for discrimination deficits in proprioception

Back 94

-same as other proprioception
-activities requiring child to demonstrate ability to grade force or efforts of movement

Front 95

Intervention for deficits in modulation of vestibular input

Back 95

-grade for type, rate of mvmt, amount of resistance
-slowly introduce linear movement w/ touch pressure in prone and provide resistance
-linear vestibular stimuli to increase awareness of spatial orientation
-rapid rotary and angular mvmts w/ frequent start/stops to increase ability to distinguish pace of mvmt

Front 96

Advanced training and knowledge of various sensory stimuli required

Back 96

-precautions for movements. impact may not be apparent for several hours.
-continually ask child how they are feeling. observe for ANS issues- sweaty palms, resp rate, pupil dilation
-compensatory skill development (environmental adaptation, handwriting support)
-reduce environmental barriers
-group treatment to develop social interaction skills to improve performance in classroom
-consult w/ teachers, parents
-share intervention strategies for specific sensory processing deficits