Chapter 12 Neurological Approaches: Eval and Intervention

Question 1

General principle/assuptions for Task-oriented approaches to Motor control training

Answer 1

• Proposes that motor control is determined by interactive systems, behavioral tasks, and adaptive/anticipatory mechanism
• movement is controlled by the integration and interaction of multiple systems (environemtnal influences, sensorimotor factors, musculoskeletal factors
• Control is not simply over muscle actions but over the interactions of kinematic variables

Question 2

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

Answer 2

• Person is an active participant whose goal is to relearn effective strategies for performing funcitonal movment.
• In the learning process, Postural adjustments and limb movment are linked.
• the learning of skills does not follow a developemntal sequence
• continued practice of compensatory strategies limits functional recovery
• Intervention is focused on learnign general strategies for solving motor problems, no learning specific movements

Question 3

Principles of the Contemporary Task-Oriented Approach

Answer 3

• After a patient has identified the most important role and occupation, therapist analyzes the task to identify the subsystems and/or environmental factors that are limiting funcitonal performance
• Intervention focused on
  
  • Practice funcitonal tasks or simlate to find effectve and efficient strategies for performance.
  • Provide opportunities for practice outside of therapy time
  • Remediating client factors
  • Adapt the environment
  • Modfy the task
  • Use assistive tech

Question 4

Motor Learning

General principles

Answer 4

• Remediating motor control in persons with CNS dysfunction. focuse on the acquisition of functiona skills that can be generalized to multiple situations and environment
• Stages
  
  • Skill acquisition(cognitive stage)
  • Skill retention state (associated stage)
  • Skill transfer stage (autonomous stage)

Question 5

Motor learning Stages and training strategies

Cognitive stage (skill acquisition stage)

• Strategies
• feedback
• organize practice
• structure environment

Answer 5

• Cognitive stage - learning the demands of the task. cognitive mapping assesses abilities, task demands, identifies stimuli, contacts memory, selects response, performs initial approximation of task, structures motor program. “What to do” decisions
• Strategies - Demonstrate ideal performance of task to establish correctness, have patient verbalize task
• select appropriate feedback (emphazise intact sensory systems, have patient watch movement for visual reference) acknowledge of successful moment outcomes
• have learning evaluate performance, identify problmes and solutions
• Organized initial practice. stress controlled movement to minimize errors. use manual guidance
• blocked (repeated ) practice of same task to improve performance
• use variable parctice (serial or random practice order ) to increase depth of cognitive processing and retention
• use mental practice
• Structure environment - reduce extraneous environemtnal stimuli to ensure attention, concentration,. emphasize closed skills progressing to open skills
  *

Question 6

Associated Stage (Skill Retention)

• Strategies
• feedback
• organize practice
• structure environment

Answer 6

Patient practices movements, refines motor programs; spatial and temporal organization, decreases errors, extraneous movements. dependence on visual feedback decreases, increases for use of proprioceptive feedback, cognitive monitoring decreases “how to do” decisions.

• Feedback/feedback schedule - Provide Knowledge performance (KP) focus on errors that become consistent, do not cue on large number of random errors. assist learning to improve. provide feedback for continuing motivatin. focus on variable feedback to improve retention
• Organize Practice - Encourage consistency of performance. Focus on variable practice order random to improve retention
• Structure environment - progress toward open, changin environment, prepare the learner for home, community, work environment.
  *

Question 7

Autonomous stage (Skill transfer stage)

• Strategies
• feedback
• Organize practice
• structure environment

Answer 7

Client practices movements, continues to refine motor responses, spatial, and temporal highly organized, movemnts are largely error free, minimal level of cognitive monitoring. “how to succeed”

• Strategies - assesses need for concious attention, automaticity of movements
• Feedback - learner demonstrates appropriate self evaluation, decision-making skills, provide occasional feedback when errors are evident
• Organize Practice - stress consistency of perfomance in variable environments. variations of task
• Structure environement - Vary environments to challenge learner, ready the learner for home, community, work environments
• Structure environment -

Question 8

Types of Ptractice within the Motor learning FOR

Answer 8

• Random (variable ) - proactice involved practice of several tasks that are presented in a random order, encouraging reformualiton of the solution to the presented motor problem
• Blocked - repeated performance of the same motor skill
• Practice of the whole task
• Practice of the parts of the task
• Variable conditions involve practice of skills in various contexts to improve transfer of learning and retention of skills
• Mental practice involves cognitive rehearsal of a skill without actually moving.
  *

Question 9

Feedback types

• Intrinsic feedback
• Extrinsic feedback

Answer 9

• Intrinsic feedback - Information received by learner as a result of performing the task. Infomation is received from tactile, vestibular, and visual systems during and after task
• Extrinsic feedback - feedback provided from an outside source. Verbal feedback about the process or performance known as knowledge of performance. Therapist provides feedback about outcome or end product as a result of the motor action.

Question 10

Factors/conditions that promote generalization of motor learning

Answer 10

• Capacity to generate intrinsic feedback
• , low extrinsic feedback regarding knowledge of results.
• Practice conditions that are variable.
• Whole task performance.
• high contextual inteference utilizes environmental conditions that increase the difficulty of learning.
• Practice in natrual istic settings

Question 11

Treatment Sequence to promote generalization of learning

Answer 11

1. Initial task if the first actiivty performed by the patient
2. Near transfer is an altertante form of the initial task
3. Intermediate transfer has a moderate number of changes in task parameters but still has some similarities to the initial task
4. Far trasfer introduces an activity that is conceptually the same as but physically different from teh initial task
5. Very far transfer requires spontaneous use of the new strategy in daily functional activities

Question 12

Task Categories

• Closed Tasks
• Variable motionless task
• Consistent motion tasks
• open tasks

Answer 12

• Closed tasks - activities performed in a stable predictable environment with consistance performance
• Variable motionless task - performed in a stable predictalbe envrionment, specific features of the environment will vary between performance trials
• consistent motion tasks - client performes task where the environmental conditions are in motion. The motion is consisten adn predictable between trials
• Open tasks - performed where client is required to make adaptive decision about unbredictable events because objects ithin the environment are in random motion during task.

Question 13

Gereral infor about sensory motor or traditional approaches such as NDT, PNF, Brunnstrom, and Rood approach

Answer 13

• Approaches are utilized for persons with central nervous systems dysfunciton
• assumptions/principles
  
  • controlled movment is preceded by stereotypic reflex responses
  • sensory input regulates motor output and sensation is necessary for movment to take place
  • The use of “facilitation” and “inhibition” techniques can improve motor performance.

Question 14

Nurodevelopmental Treatment (NDT)/ The Bobath Technique

• Principles
• Evaluaiton procedures
• Interventions

Answer 14

• Principles -
  
  • Normalization of postural and limb tone is prerequisite to normal movment (abnormal tone =faccidity(low tone) and spasticity (high tone))
  • Avoidance of movments and activities that increase tone. Inhibition of primitive reflexes and abnormal postural and limb movements.
  • Improvement of the quality of movment and perfornace of the involved side.
  • Focus on improving the quality of movement by 1. normalization of movement patterns 2. Integration of both sides of the body/restablishment of symmetry of the sides of the body to increase functional use. 3. establish the ability to weight bear and weight shift throught the limbs, 4. establish normal righting and equilibrium patterns
• Evaluation procedures - Observe malalignments in teh trunk and limbs in various postures. Evaluate abnormal tonal patterns in the trunk limbs during passive movements. eval ability to hold posture without therapist support.
  
  • postual control - righting reactions, equilibrium reactions, protective responses, weightshifting activities
  • abnormal coordination patterns of the limbs focusing specifically on timing of movements, sequencing of meovments, coordination of muscle activation.
• Interventions -
  
  • Handling - provide external stability during movment, normalize movment patterns, facilitate or inhibit specific muscle groups. inhibit abnormal patterns of control, provide sensory input.
  • Normalize tone - Weightbearing through the involved trunk and linb to inhibit spastic patterns, and to facilitate underactive muscl egroups, trunk rotation, scapula mobilization, pelvic alighment and weightshift, slow and controlled movements. proper positioning in bed, chair etc
  • utilize bilateral movment patterns to indetrate both sides of the body into function.

Question 15

Proprioceptive Neuromuscular Facilitation (PNF)

• Pinciples/assumptions
• Evaluaiton Procedures
• Interventions

Answer 15

• Principles/ Assumptions -
  
  • Teh response of the neuromuscular mechanisms can be hastened through stimulation of proprioceptors.
  • Normal motor development proceeds in a cervicocaudal and proximodistal direction.
  • Normal movment and posture depend upon”synergism” and balanced interactions of antagonists
• Evaluations Procedures -
  
  • Eval reflects the develpmental sequence proceeding in a proximal to distal direction,
  • eval vital functionas such as respiration, swallowing, voice production, and oral facial movements for asymmetry.
  • Diagonal patterns
  • During movment, not dominance of flexor or extensor tone, midline alignment, stability and mobility in various patterns, influence of head, neck and trunk patterns, ROM, quality of movement
  • Timing of movements
• Interventions - Diagonal patterns or mass movement patterns utilized during functional activities. Patterns are chosen in an effort to remediate missing components,

Question 16

Pattern Analysis of diagonal patterns

• D1 Flexion (UE)
• D1 Extension (UE)
• D2 Flexion (UE)
• D2 Extension (UE)

Answer 16

• pg 262 for full diagram refer to the pictures
• D1 Flexion (UE) -
• D1 Extension (UE)
• D2 Flexion (UE)
• D2 Extension (UE)

D2 commands

1. Ready look at your hand
2. open and turn your hand, thumb toward your face
3. lift up and out
4. now close your hand
5. pull down and across. and repeat and again.

D1 Commands

1. Ready, look at your hand
2. Close and turn your right hand toward your face,
3. pull up and accross
4. Now Open your hand
5. push down and away, and repeat, and again

Question 17

PNF techniques to promote reversal of antagonist

Answer 17

• Slow reversals are utilized to gain range of motion. alternating isotonic contraciont of antagonists.
• Rhythmic stabilization is the siultaneous idometric contractions of antagonists, resulting in cocontraction and thereby promoting stability

Question 18

Brunnstrom levels of motor recovery

stage 1-7

Answer 18

• NOTE!! These principles and techniques are not reflective of current understanding of the motor system
• stage 1 - flaccidity, no voluntary or reflexive activity
• Stage 2 - Minimal voluntary movement, components of the synergies are elicited as reflex reactions. Spasticity begins to develop.
• stage 3 - Marked spasticity, synergies are performed voluntarily
• Stage 4 - Movements that begin to deviat from synergy can be accomplished on a volitional basis
• Stage 5 - Movments which differ greatly from the basic synergies are utilized
• Stage 6 - Spasticity is essentially absent: isolated muscle actions are freely performed
• Stage 7 - normal motor function

Question 19

Evaluation of Motor Control Dysfunction

Assessing spasticity

Answer 19

• The limb is quickly stretched in a direction opposite the pull of the musle group being tested
  
  • objectively measured by a 5 point ashworth scale 1-5 (5 severe hypertonus/rigidity) or Modified Ashworth Scale 0-4
  • graded min/mod/severe (Minimal if “catch” is felt at end range and severe if catch is felt at beginign of end range

Question 20

Evaluation of Motor Control Dysfunction

Reflex testing

Answer 20

• reflexes may be released after brain injury or not integrated during early development secodary to CNS pathology.
• A resononse to a stiulouse is termed Positive and no response is “negative”
• Example of refelxes tested (review developmental reflexes)
  
  • grasp, flexor withdrawal, crossed extension, ATNR, STNR, tonic labrinthine (prone and supine), positive supporitng reaction, associated reactions, neck righting, optical righting, protective extension, equilibrium reactions

Question 21

Qualitative descriptions of Motor control

• Intention tremor
• Dysmetria
• Dyssynergia
• Dysdiadochokinesia
• Ataxia
• Resting Tremor

Answer 21

• Intention tremor - is a worsening of action tremor as the limb approaches a target in space.
• Dysmetria - undershooting (hypometria) or overshooting (hypermetria) of a target
• Dyssynergia - a breakdown in movment resulting in joints beign moved separately to reach a desired target as opposed to moving in a smoth trajectory, decomposition of movement.
• Dysdiadochokinesia - is impaired ability to perform rapid alternating movements
• Ataxia - loss of motor control including tremors, dysdiadochokinesia, dyssynergia, and visual nystagmus
• Resting Tremor - an involuntary tremor noted in resting positions

Question 22

Qualitative descriptions of Motor control

• Rigidity -
• Bradykinesia
• Akinesia
• Athetosis
• Dystonia
• Chorea
• Hemiballismus

Answer 22

• Rigidity - increased resistance to passive movment throught the range; may be “cogwheel” alternative contraction/relaxation of muscles being stretched, “lead pipe” consistent contraction throughout range
• Bradykinesia - overall slowing of movement patterns
• Akinesia - in ability to initiate movement patterns
• Athetosis -dykinetic condition that inclues inadequate timing, force, and accuracy of movements in trunk/ limbs, movments are writing and worm-like
• Dystonia - an invonuntary sustained distorted movement or posture involving contraction of groups of muscles
• Chorea - involuntary movements of the face and extremities which are spasmodic and of short duration
• Hemiballismus - Unilateral chorea characterized by violent, forceful movements of the proximal muscles

Question 23

Assessing Glenohumeral joint Subluxation

Answer 23

• allow person’s arm to dangle
• palpate the space underneaththe acromion process with inde finger.
• Compare to the intact side and document the width of space in terms of finger breadths.

Question 24

Purpose of Splint/Orthotic for Neuromotor Dysfunction

Answer 24

• Prevent/Correct deformity via prolonged stretch and proper alignment
• Control spasticity by aligning joints and providing prolonged stretch to spastic muscles
• Prevent/decrease/acccommodate contractures of joint or soft tissue
• Position the hand in a functional posture to promote engagement in activities.
• provide proximal support
• support a painful joint
  *

Question 25

Splint Classifications * Static splint * Dynamic splint

Answer 25

* Static splint - no moving parts, utilized for external support, prevention of motion, stretching of contractures, aligning joints for healing, resting joints or reducing pain * Dynamic splint - moving parts, splints have resilietn compents (bands or springs) and are used to increase passive motion, assist weak motions or substitute for lost motion

Question 26

Hand/wrist based splints * Cock-up splint * Resting hand splint * Opponens splint

Answer 26

* Cock-up splint - supports the writs in 10-20 degrees of extension to provent contracture. allows digits to function to suport flaccid wrist * Resting hand splint - Usted for persons who need to have their wrist, digits, ant thumb supported in a functional positin for prolonged period ie treating contracture from long flexors. * Opponens splint - Designed to support the thumb in a position of abductin and opposition. Utilized during functioanl activities to compensate for weakness Patterns.

Question 27

Types of inhibitory/tone normalizing orthoses * Bobath finger spreader * Orthokinetic splints * Spsticity reduction splint * Rood cone

Answer 27

* Bobath finger spreader - Soft splint positions the digits and thumb in abduction in an effort to reduce tone * Orthokinetic splint - Utilizes tactile input (via elastic bandage) to facilitate or inhibit appropriate muscle groups. * Spasticity reduction splint - places the spastic distal extremity on submaximal stretch to reduce spasticity. * Rood cone - Cone-shaped splint is utilized to reduce flexor spasticity in the hand.

Question 28

Types of supportive orthoses

Answer 28

* Overhead suspension sling * balanced forearm orthoses * shoulder slings

Question 29

Overhead suspension sling

Answer 29

* incorporates an arm support that is supported by a sling and suspended by an over head rod * used with persons presenting with proximal weakness (ALS, Guillian-Barre syndrome, muscular dystrophy) with muscle grades 1 to 3

Question 30

Balanced forearm orthoses Mobile arm supports or ball bearing forearm orthoses

Answer 30

* Consists of an arm trough, proximal and distal arms, and a suport bracket * Allows a patient with weak proximal muscularture to utilize available control of the trunk and shoulder to engage in functional tasks

Question 31

Shoulder slings

Answer 31

* Utilized to support a flaccid arm after neurologic insult for short and controlled periods of time * **long term use may be detrimental in terms of soft-tissue contracture, edema, and the development of pain syndromes** **\***Supports may be utilized on a wheel chiar to position a flaccid arm (lab boards, arm trough)

Question 32

Splinting Considerations

Answer 32

* wearing schedules must be prescribed to enhance the function of the splint, Splints that are used to decrease spasticity or reverse contractures require longer wearign times * splints must be monitored for pressure over bony prominences * Donning/doffing procedures should be reviewed with indivduals and caretakers and be documented. * The appropriate material must be chosen by the inclusion of necessary characteristics including resistance to stretch, memory, conformability/drape, rigidity/flexibility, and self/adherence.

Question 33

Oral Motor Dysfunction * Presentation of Dysfunction * Evaluation

Answer 33

* Presentation of Dysfunciton - Dysarthria (speech impairments), Dysphagia (swalowing impairments) or psychosocial stresses related to facial asymmetry and/or drooling * Evaluation * ROM, strength, and tone of the lips, cheeks and tongue * Sensation * Oral control of bolus (contain the bolus in teh oral cavity, form a cohesive bolus, propel the bolus posteriorly into the pharynx * swallow reflex (layngeal elevation when teh larynx rises to approximate the epiglottis and protect the airway, soft=alate elevation when teh soft palate rises to close off the naso-pharynx to prevent food/liquid from entering the nasal cavity, peristaltic waves of muscle contraction to propel food. * Airway protection (gag reflex, cough to clear pharynx * Primitive reflexes * rooting - Pathological response includes head turning toward direction of the stimulus * Jaw jerk - tap the center of the mandible firmly 1-2 times. pathological response includes reflexive jaw closure/opening * Bite reflex - a tongue depressors is placed lightly betwwn the upper and lower teeth, a reflexive bite indicates pathology. * Barium Swallow study

Question 34

Cranial nerve testing 1-6

Answer 34

* I - Olfactory (S) ask person to sniff various aromatic substances * II - Optic (S) Eyechart testing, visual field testing * III - Oculomotor (M) Medial and vertical eye movements, pupil sizes, pupillary reflex, visual tracking * IV - Trochlear (M) Downward and inward eye movements, eye tracking * V - Trigeminal (B) Control jaw movements, face sensory. Pain, touch, and temp, corneal reflex, move jaw * VI - Abducens (M) lateral eye movements. eye tracking

Question 35

Cranial nerve testing 7-12

Answer 35

* VII - Facial (B) tastembuds and facial expressions. have them taste various taste and make faces * VIII - Vestibulochochlear (S) equilibrium and hearing. test with tuning fork * IX - Glossopharyngeal (B) Motor for pharynx and salivary glands. Taste sensation. gag and swallow refelxes. posterior 3rd of tongue tested for taste * X - Vagus (B) larynx and pharynx. tested in conjunction with 9. * XI - Spinal Accessory (M) movements of neck and shoulders * XII - Hypoglossal (M) tongue movement. ask person to stick out tongue

Question 36

Intervention for Oral Motor Dysfunction * Direct therapy that involves techniques that utilze a bolus * Indirect therapy involves procedures that do not include use of a bolus

Answer 36

* Direct therapy - * Modification of consistency, amount, and pacing of solids and liquids. * Utilizing postural interventions to increase swallowing efficiency during meals (chin tuck, head tilt, head turn) * Swallowing adaptations (supraglottic swallow technique to voluntarily close/protect the airway) (Mendlesohn maneuver (voluntarily prolonging the rise of the larynx by prolonging tongue contraction) * Indirect therapy - * thermal stimulation - sensory input to inveriour faucial arches to ellicit a swallow reflex * reflex facilitation, strengthening, facilitation and coordination of oral movements * airway adduction procedures * Positioning to maintain the trunk/head and neck in correct postures.

Question 37

Limb and Postural Control Impairments Constraint Induced Movement Therapy General Information and inclusion criteria

Answer 37

* Motor Inclusion criteria - * 20degrees of extension of the wrist and 10degrees of or extension of each finger. * 10 degrees of extension of the wrist 10degrees of abduction of the thumb and 10d of extension of any two other digits . * able to lift a wash rag off a table top using any type of prehension and then release it.

Question 38

CIMT intevention

Answer 38

* Massed practice of affected limb while less affected upper extremity is constrained * The therapist designs practice of functional tasks or close simulatioins. Provide homework, assignments training, etc. * Adaptations to the environment, task modification, assitive tech, * for persons with poor control of movement, constrain the degrees of freedom to enhance performance.

Question 39

Sensory Integreation Frame of reference for Sensory Processing Disorder Principles/ Assumption of Sensory Integration

Answer 39

* view of neural organization of sensory information for an adaptive response * Plasticity - structural changes of teh central nervous system allows for modification of the CNS * Adequate processing and organizaiton of sensory stimuli by lower brain centers are needed for higher cortical processing functions * Sensory stimuli modulation is needed for and adaptiv eresponse to occur. Adaptive responses facilitate the integration of sensory stimuli.

Question 40

Evaluatoin of Sensory Processing Disorders * Sensory Integration and Praxis Test * Test of sensory funcitons in Infants * Sensory Processing Measure * Informal/Formal observation

Answer 40

* SIPT - 4-8 year olds. measures of tactile and vestibular-proprioceptive sensory processing, tests of forma dn space perception and visual motor coordination, test of practic ability, measures of bilateral integration and sequencing * TSI - test for children 1-18monthsassess the level of responsiveness to a variety of sensory stimuli. * SPM - elementary school children. measures sensory processing, praxis, and social participation. asseses visual auditory, tactile, olfactory-gustatory, porprioceptive and vestibular behaviors. * Informal/Formal Observation - clinical observations, classroom, playground, home observations, assess certain reflexes, corssing body midline, bilateral coordination, muscle tone, Consider contexts of test. interview parents and teachers.

Question 41

Sensory Integration Intervention General concepts

Answer 41

* Control sensory input to improve sensory processing, facilitate sensory integration and elicit an adaptive response. * grade movments - easier to more challenging * firm pressures to light touch * linear movement to angular * slow movement to rapid movement * Gradually introduce activities requiring more mature and complex patterns of behaviors. * Promote organized adaptive responses to enhance a child's general behaviroal organization, including socialization.

Question 42

Specific Sensory Processing deficit Interventions Tactile modulation

Answer 42

* Tactile modulation - tactile defensiveness, hypersensitivity, over responsivitiy and hyposensitivity/under responsivity. and sensory seeking * self-applied stimulie are more tolerable than passive application * Provide deep touch where child is able to see source. begin with slow linear movmemnts and deep touch pressure * apply tactile stimuli with joint compression (propioceptive input) * monitor behavior hours after treatment. tactile defensivenes and sensory seeking can be reduced if tretment is effective

Question 43

Specific Sensory Processing deficit Interventions Tactile discrimination

Answer 43

* Provide deep touch pressure to hands and the body * Deficits in tactile discrimination are hardly seen in isolation. treatment is simultaneously treated with deficits in motor planning * Graded activites include introducign a mixture of texture and items

Question 44

Specific Sensory Processing deficit Interventions Proprioception modulation deficit

Answer 44

* Deficits in modulation demonstrated by over-responsivity/ underresponsivity and sensory seeking * provide firm touch, pressure, joint compression, or traction * provide resistance to active movement to help the child learn force needed to perform tasks * Provide activities in various body positions * provide slow linear movment, resistance and deep pressure, * adaptive techniques.

Question 45

Specific Sensory Processing deficit Interventions Proprioceptive discrimination deficit

Answer 45

* provide activities require the child to demonstrate the ability to grade the force or efforts of movement. * Provide firm touch, pressure, joint compression traction. * provide resistance to active movement to help th child learn the amount of force needed for the task

Question 46

Specific Sensory Processing deficit Interventions Vestibular modulation deficits

Answer 46

* Presents as over responsivity/underresponsivity, (hypersensitivying sensory seeking and gravitational insecurity) * Grade for type and rate of movement and for amoutn to resistance * Slowly introduce linear movement with touch pressure in prone and provide resistance to active movements, especially for gravitational insecurity. * Use linear vestibular stimuli to increase awareness of spateial orientation * Provide rapid rotary and angular movement with frequent starts and stops to distinguish the pace of movement.