Question | Answer |
Common Assumptions underlying Neurophysiologic treatment approaches on how the CNS controls movement | - four approaches will be emphasized.
- Approaches are to help normalize muscle tone and promote normal movement patterns.
-overlapping concepts - encouraged to mix and match for pt. tx |
The four approaches presented in this section are: | - Brunnstrom
- Rood
- PNF
- NDT |
There are several ways to manage tone. They include but are not limited to the following five techniques: | 1. Neurophysiological treatments (Brunnstrom, Rood, PNF, NDT)
2. serial casting
3. orthotics/splinting
4. biofeedback/ E- Stim
5. medications
(MEDS OUT OF SCOPE PT/PTA) |
BRUNNSTROM | -studied CVA's
-theorized that basic limb synergies (abnormal mvmnt patterns) were primitive reflex patterns.
-concluded that CVA pt. progress thru predictable stages of recovery
-some remain in stages permanently - do not progress thru all |
TIP 1: Not unusual to find that the UE's & LE's are at different stages | TIP 2: LE is usually less affected than the UE. |
STAGES OF RECOVERY ACCORDING TO BRUNNSTROM | Must move through all stages - no skipping stages - some pt. do not make it to the end stage, they remain in a given stage and exhibit signs and symptoms of that stage - not everything always recovers. |
Stage One (Brunnstrom) | -Faccidity Stage - no mvmnt is seen and hypotonicity is present.
- at risk for sublaxation
-FACILITATE IN THIS STAGE |
Stage Two (Brunnstrom) | -Beginning synergies thru associated reactions or voluntary attempts.
- Hypotonicity is beginning to move towards hypertonicity
- may feel some muscle tension with ROM
-FACILITATE TOWARDS SYNERGY PATTERNS IN THIS STAGE |
Stage Three (Brunnstrom) | - Synergy obligated- synergy patterns are strong
- primitive, automatic, and difficult to control
-pt remain here a long time
- severly involved may never go further
-INHIBIT SYNERGY PATTERNS IN THIS STAGE |
Stage Four (Brunnstrom) | -When the pt. progresses and spacticity begins to decrease
- some mvmnt combos outside of the abnormal synergy start to emerge.
_INHIBIT STRONG SYNERGY PATTERNS AND FACILITATE OUT OF SYNERGY PATTERNS |
Stage Five (Brunnstrom) | - pt. continues to progress outside of the synergy patterns and there is some independent joint mvmnts although it requires great concentration.
-FACILITATE OUT OF SYNERGY PATTERNS - MAY HAVE TO INHIBIT SOME TO GET THERE |
Stage Six (Brunnstrom) | -Active and isolated mvmnts and normal tone is present.
-FACILITATE |
Generally, what stages do we as PTA's want to facilitate in? | 1, 2, 4, 5, 6 |
Which stages do we generally want to inhibit in? | 3
(also any abnormal mvmnts in 4,5,6) |
In what stages are associated reactions appropriate? | Stages 1 & 2 |
What are associated reactions? | Defined as voluntary forceful mvmnts of a body part elicit overflow of mvmnt in an involved body part.
Some Voluntarty mvmnts such as sneezing and coughing elicit these responses also.
- FACILITATE UNINVOLVED LIMB TO GET SAME REACTION IN INVOLVED LIMB. |
Ramiste's Phenomenon | -resisted hip abd/add may elicit same response in opp. limb
- resist right abd/add may elicit left abd/add
-True of UE's and LE's |
Homolateral limb synkinesis | -resisting the UE on one side may get the same response in the same side LE
-example - resisted shoulder flexion in the right UE may elicit Right LE hip flexion. |
Bilateral UE | resisted, the right UE or LE may elicit the same response in the left UE or LE
- |
Bilateral LE | -resisted motion in one extremity may elicit the opposite response in the opposite extremity
- remember flexor withdrawl |
Soques's Phenomenon | -raising the arms overhead may elicit finger extension
- use in flaccid stage one or two |
Primitive reflexes like ATNR and STNR | -turn head to the right may elicit right UE extension and left UE flexion |
SYNERGY PATTERNS | UE FLEXION
UE EXTESION
LE FLEXION
LE EXTENSION |
UE Flexion Pattern | shoulder flx, elevation, and/or retraction, abduction, and external rotation\
elbow flx,
forearm supination,
wrist flx, and
finger flx |
UE Extension Pattern | Shoulder depression, and/ or protraction, adduction, and internal rotation
elbow ext.
forearm pronation,
wrist ext. and
finger ext. |
LE Flexion Pattern | Hip flx, abduction, and external rotation,
knee flexion,
ankle dorsiflx,
footinversion, and
toe ext. |
LE Extension Pattern | Pelvic retraction, and/or elevation
Hip ext., adduction, and internal rotation,
knee ext,
ankle plantarflx,
foot inversion,
and toe flx. |
GENERAL PRINCIPLES OF SYNERGY PATTERNS | There are several general principles to consider when working with patients with synergy patterns. These include the strongest components of the pattern, as well as other reminders |
Which pattern usually predominates in the UE? | UE Flexion Synergy Pattern |
Which pattern usually predominates the LE? | LE Extension Pattern |
In the UE Flexion Pattern, which component is dominate? | Elbow Flexion |
In the UE Extension Pattern, which components are strongest? | Shoulder Adduction and forearm pronation. |
In the LE Flexion Pattern, which component is the dominate one? | Hip Flexion |
In the lE Extenion Pattern, which components are the strongest? | Hip adduction, knee extension, and plantarflexion |
Typically the strong components are ___________ to show up and ________to leave. | first to show up and last to leave. |
The strong components tend to ________. If you _________ those components, the rest will ___________. | -strong components tend to lead
-Inhibit those and the rest will follow. |
TIP One: Elicit dominate components in flaccid arm or leg but be careful, we want ISOLATED joint mvmnts NOT multi joint patterns | TIP TWO: Inhibit the multi joint mvmnts and encourage isolated joint mvmnts |
How can we encourage isolated joint mvmnts? | -Facilitation/inhibition techniques, NDT, PNF
-Most always functional activities are included as well |
Movement Patterns Associated with Stage Four- indicate a pt has progressed to Stage Four | - In sitting, knee flx beyond 90 with the foot sliding backwards on the floor.
-Active dorsiflx w/out lifting the heel off the floor
-Hip flx past 90
-Partial finger ext. |
Movement Patterns Associated with Stage Five- indicate a pt has progressed to Stage Five | - Standing, isolated nonweightbearing knee flx, hip ext, (or nearly)
- Stand, isloated dorsi, knee ext. heel forward in a position of a short step
OR Sit w isolated dorsi w knee ext
-isolated ankle eversion to/from inversion w knee ext
-full finger |
MARGARET ROOD | OT/PT - primarily worked with CP kids |
General principle of Rood #1 | Because motor control output is dependent on sensory input, sensory stimuli are used to activate, facilitate, or inhibit motor responses.
-Usually followed by some kind of functional activity or positioning so the body can relearn "normal" fashion. |
Three kinds of sensory receptors we typically use ? | -Exteroceptors
-Proprioceptors
-Vestibular receptors |
Exteroceptors | superficial and can cause reciprocal innervation (senses such as tactile and temp.) |
Propioceptors | give us muscle awareness (GTO, spindles, joint receptors) |
Vestibular receptors | semicircular canals |
The responses we look for with ROOD are: | -Activation
-Facilitation of Normal Muscle Tone
-Inhibition of abnormal muscle tone |
What are we looking for with Activation (Rood) | -Elicit a response you don't see or have not seen before - usually sensory stim. (i.e. pt in coma) |
What are we looking for with facilitation of normal muscle tone? (Rood) | -Enhance a reaction or an existing motor response, changing the quality of a response so that it is stronger, more controlled, or coordinated. |
What are we looking for with inhibition of abnormal muscle tone? (Rood) | -Decrease an existing motor response to allow a more adaptive or productive pattern to emerge. |
General Principle of ROOD #2 | -Look for homeostasis in tx
-Balance between the sympathetic and parasympathetic (the autonomic nervous system)
-Important because it will influence the pt. response to stimuli. |
What are some examples of ways to include the principles of ROOD in tx? | -tone of voice
-rhythmical mvmnts
-neutral warmth
-ice
-joint compression
-tapping
-vibration
-slow rolling
-prolonged passive stretch
-firm tendinous insertion pressure
-weight bearing
-ECT.
-NOTE:can use individually or in combos. |
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