NM3 Practical Exam Format
Diagnoses-
STROKE:
a) Brunnstrom’s stage of stroke recovery
o Stage 1. Flaccidity: No movement
o Stage 2. Spasticity begins- Involuntary associated reactions, but no voluntary movement
o Stage 3. Spasticity worsens- Voluntary movement in synergy
o Stage 4. Spasticity declines-SOME voluntary movement out of synergy (some isolated movement)
o Stage 5. Spasticity declines more, independent from synergistic movement (mostly isolated movement)
o Stage 6. Spasticity disappears, all isolated movements present. Coordination/speed near normal
b) Right/left sided brain characteristics
o Right: Safety risk, impulsive, unaware of deficits, often see L neglect, emotional
o Left: slow, confused, depressed, aware of deficits, aphasia (expressive and receptive), apraxia(can’t execute task)
c) Stroke locations and common impairments:
o ACA- Mostly LE, confused
o MCA- Mostly UE, visual and spatial deficits
o PCA- visual deficits
d) Synergy Patterns:
o UE: Flexion= Scap elevation, shoulder abduction/ER, elbow flexion, forearm supination, wrist and finger flexion**
o Extension= scap protraction, shoulder add/IR, elbow ext, forearm pronation, wrist ext, finger flex
o LE: Extension= Hip ex, add, IR, knee extension, ankle PF/inversion, Toe PF**
o Flexion- hip flexion, abd, ER, knee flexion, ankle DF/Inversion, toe DF
PARKISON’S DISEASE
a) Hoehn/Yahr Classification of PD: in stages of progression
I. Stage 1-Unilateral symptoms
II. Stage 2-Bilateral symptoms
III. Stage 3-Postural instability
IV. Stage 4- All symptoms are severe, not independent
V. Stage 5- Wheelchair/bed bound
b) 4 Cardinal Features
1. Tremor
2. Rigidity (leadpipe, cogwheel, masked face)
3. Bradykinesia (akinesia)
4. Postural Instability (retropulsion/pull test)
Fall into two groups:
§ Postural Deformity and gait disturbances (stooped/kyphosis) (festinating gait/shuffle)
§ Tremor predominant (younger onset) slower progression
MULTIPLE SCLEROSIS
o Altered sensation, problems with vision
o pain, numbness tingling- All 4 limbs, trunk, face
o Unsteady gait, slowed movement- muscle weakness
TRAUMATIC BRAIN INJURY
o Depends on where the lesions were, front-memory/personality/higher level function?, back-vision, temporal-speech, hearing, and understanding? Brain stem- basic level function
VESTIBULAR
Pathologies:
1. Vestibular Neuritis (Neuronitis) & Labyrinthitis:
àRehabilitation: necessary for balance and gaze stabilization if symptoms persist
2. Benign Paroxysmal Positional Vertigo (BPPV):
-Canalithiasis: Calcium carbonate crystals are free floating in the SCC
-Cupulolithaisis: Calcium carbonate crystals from utricle adhere to cupula
BPPV Treatments:
• Epley’s maneuver/CRT: posterior or anterior SCC BPPV
(Patient starts rolled toward problematic side and ends facing away from problem side)
• Particle repositioning procedure (BBQ roll): Horizontal SCC
• Semont/Liberatory maneuver: posterior canal BPPV
(patient starts rotated away from problem side)
Gaze Stability (VOR) Treatment:
1. X1 Viewing:
A. Distance Target:
• Stand 6 to 10 feet from target
• Move head horizontally back and forth while focusing on target. Move head as fast as possible while maintaining target in focus. Perform for 1 minute without stopping.
• Rest
• Repeat with vertical head motions for 1 minute without stopping. Rest
B. Near Target
• Repeat above with near target. Target held in hand at arms length.
• Can be sitting or standing
C. Target within a “full-field”
• Hold a checkerboard with target placed on it in your hand. (About arms length)
• Move head horizontally back and forth while focusing on target. Move head as fast as possible while maintaining target in focus. Perform for 1 minute without stopping.
• Rest
• Repeat with vertical head motions for 1 minute without stopping. Rest
2. X2 Viewing:
A. Near Target
• Can be performed sitting or standing
• Target held in hand at arms length
• Move head and target horizontally from side to side in opposite directions. Move head as fast as possible while maintaining target in focus. Perform for 1 minute without stopping. Rest
• NOTE: Speed of movement is slower than X1 viewing and amplitude of head movement (and target) will be smaller.
• Repeat with vertical head motions, moving target and head in opposite directions for 1 minute. Rest
B. Target within a “full-field”
• Hold a checkerboard with target placed on it in your hand. (About arms length)
• Move head and checkerboard horizontally from side to side in opposite directions as fast as possible while maintaining target in focus.
• Perform for 1 minute without stopping. Rest
• NOTE: Speed of movement is slower than X1 viewing and amplitude of head movement (and target) will be smaller.
• Repeat with vertical head motions, moving head and checkerboard in opposite
directions for 1 minute. Rest
3. Active eye-head movements between two targets: (Eyes move first, then head catches up)
• Place two targets on wall about 2 feet apart. (Place close enough together that when looking at one target, you can see the second target out of the corner of your eye).
• Look at one target making sure head is also lined up with target
• Then, keep head still and move only eyes to second target. Then turn head to second target. (Eyes should move before head).
• Be sure to keep target in focus.
• Repeat in opposite direction
• Perform for 1-3 minutes, resting as needed.
• Can also be performed with 2 vertically placed targets.
• Vary speed of head movement, but always maintain target in focus.
4. Imaginary Targets: (Separates out eye from head)
• Use a target directly in front of you
• Close eyes and turn head horizontally, imagine that you are still looking directly at the target
• Open eyes and check to see if you have been able to keep eyes on target
• Repeat in opposite direction
• Vary speed of head movement
• Perform for up to 3 minutes.
• Rest as needed.
• (Can use near or distance target; can move head horizontally and/or vertically)
Gaze Stabilization‐Treatment Variables
1.Duration (most important aspect of prescribing x1 or x2 viewing)
2.Background Distraction
3.Position
4.Speed
5.Frequency
Gaze Stabilization‐Treatment Considerations (for practical)
1.Image must be stable
2.Observe patient’s eyes
3.To take a step forward, may need to take a step backward
4.Avoid over stimulation
5.All patients will not progress through all stages
Gaze stabilization‐Functional Goals
1.Turn head while conversing
2.Brush teeth
3.Perform household chores
4.Ride in a car & identify street signs
5.Shop in grocery store
ATAXIA
o Celebellar Dysfunction
o Treatments focusing on strategies to reduce the complexity of a movement by reducing the number of moving joints will improve movement
o Teach control of movement through dynamic stability and proprioceptive stimuli.
Treatment Suggestions
• Weights – adding approximation to the limb
• - 3 – 5kg ankle, knee or waist belts improved functional balance in 11/14 patients with ataxia.
• Pelvic weighted belt – decreased postural sway in healthy subjects
• Treadmill training and BWSTT
• Visually guided stepping
• Behavioral relaxation
• UE – cooling, wrist weights,
• Aerobic conditioning
• Hydrotherapy and Hippotherapy – no direct evidence but anecdotal
• Yoga and Pilates
Outcome measures-
o Berg Balance (static balance, falls risk)- TBI, MS, PD, Stroke, Vestibular, CP
o 2 minute walk test (endurance)-TBI, MS, SCI, CP
o 10 meter walk test (gait velocity)-TBI, MS, SCI, Stroke, Vestibular, CP
o MINI Best (balance evaluation- dynamic balance) TBI, Ataxia, MS, PD, Stroke
o TUG
o DGI
o 6MWT/10MWT
o 30 Second Sit to Stand
o OM for pushing (scale of contraversive pushing
Classifications and Scoring:
Balance (static and dynamic- unchallenged and challenged)
SITTING Scoring:
Poor- pt requires handheld support with mod/max A to maintain sitting posture.
Fair- pt maintains balance with handheld support, may require occasional min A
Good- pt maintains balance without handheld support, limited postural sway.
Normal- pt maintains balance without handheld support
STANDING Scoring:
Poor- pt unable to perform.
Fair- pt accepts minimal challenge, able to maintain balance while moving head/trunk
Good- pt accepts moderate challenge, able to maintain balance while picking up object from floor
Normal- accepts maximum challenge, able to weight shift easily through full range.
Modified Ashworth Scale- Tone
· 0 No increase in tone (normal)
· 1 Slight increase in tone, end of range(catch + release)
· 1+ Slight increase in tone through less than ½ the range
· 2 Marked increase through most of the range (still moves easily)
· 3 Passive movement difficult
· 4 No movement
RANCHO LOS AMIGOS SCALE AKA Level of Cognitive Functioning Scale-TBI
1. Level 1- No response
Ø Treatment: Sensory stimulation techniques (music, smells, tastes, pictures)
- Level 2- Generalized response: reflex response to painful stimuli, no purposeful reactions/may be the same for different stimuli
Ø Treatment: Sensory stimulation techniques (music, smells, tastes, pictures)
Ø Treatment: Simple 1-step directions, gross motor activities
- Level 3- Local response: withdrawal/vocal to painful stimuli, purposeful reactions to different stimuli (turn away from pain, blink with bright light), response inconsistently
Ø Treatment: Simple 1-step directions, gross motor activities
- Level 4- Confused Agitated: Alert and heightened state, tries to remove stimuli (perceived as noxious)
Ø Treatment: Calm, soothing atmosphere, simple and repetitive tasks, functional training
- Level 5- Confused, Inappropriate: Alert, not agitated, may wander randomly. Not oriented, unable to learn new information.
Ø Treatment: Calm, soothing atmosphere, simple and repetitive tasks, functional training
- Level 6- Confused, Appropriate: Inconsistently oriented, vague recognition and memory, unaware of impairments.
Ø Treatment: daily routine, decrease help and increase strength and coordination, orientation activities
- Level 7- Automatic, Appropriate: Consistently oriented, Unaware of others needs/feelings and unable to think about consequences, superficial awareness of impairments.
Ø Treatment: Increase patients insight/ability to recognize tasks and therapy, increase endurance and idependence
- Level 8- Purposeful, Appropriate: Independently attends to needs and tasks, thinks about consequences, depressed, aware of deficits.
Ø Treatment: Encourage memory and details, evaluate self
Hoehn/Yahr Classification of PD:
I. Stage 1-Unilateral symptoms
II. Stage 2-Bilateral symptoms
III. Stage 3-Postural instability
IV. Stage 4- All symptoms are severe, not independent
V. Stage 5- Wheelchair/bed bound
Brunnstrom’s stage of stroke recovery
1. Stage 1. Flaccidity: No movement
2. Stage 2. Spasticity begins- Involuntary associated reactions, but no voluntary movement
3. Stage 3. Spasticity worsens- Voluntary movement in synergy
4. Stage 4. Spasticity declines-SOME voluntary movement out of synergy may occur (some isolated movement)
5. Stage 5. Spasticity continues to decline, independence from synergistic movement (mostly isolated movement)
6. Stage 6. Spasticity disappears, all isolated movements present. Coordination/speed near normal
Technology/Assistive Technology: What technology would facilitate a massed practice intervention session? Or what type of seating system would be optimal for this patient? Or what type of wheelchair cushion would be optimal for this patient?
o Technology- AltG treadmill, Virtual reality/Kinect/Wii, BWSTT(Litegait), Eksoskeletons (Robotics), Apps for Tablets
o Wheelchair-
¨ Ultra lightweight wheelchair (very adjustable, folding type best if they are going to be doing transfers to/from car or public places)
¨ Foam and gel cushions, ROHO (air- gold standard)- Best if patient is able to weight shift on their own. Long term molded/custom cushions- better if patient is worried about skin breakdown/continence
Contemporary approaches to treatment from articles:
o BWSTT- Body Weight Supported Treadmill Training (utilizing body weight support from an overhead lift and harness, either over ground or a treadmill- for CVA, TBI, SCI, LE weakness)
¨ TREATMENT: Manual facilitation of step taking, increase gait speed and balance
o CIMT- Constraint Induced Movement Therapy (For UE hemi-neglect, or to increase functional use of involved limb)
¨ TREATMENT: Place glove or hand behind back for LESS involved UE, make the patient use their involved UE for as much as possible (90% waking hours). The longer time they are constrained, the better.
¨ 2 week session Monday-Friday, 9am-3pm, homeworking in evenings and on weekends
¨ inclusion criteria: many joints WFL, intact sensation/perception/language- many patients don’t meet criteria
o Pushers- Generally push due to RIGHT brain damage/hemineglect (altered perception of midline), Push using strong side towards paretic/weak side
¨ TREATMENTs:
¨ Put pushing hand in lap, apply weight bearing to opposite hand and leg
¨ Help them right themselves/align themselves with items in the room
¨ Transfer to the strong side (help push themselves into bed/chair)
¨ If you can get the pushing arm up above shoulder level, it’ll break the strength of pushing-stack pillows high on affected side and place arm on top
¨ Get them come forward is more important than sideways (ex- use big ball in front and have them lean over it)
Motor learning principles
-Task Specific, Change Environment, Consider stage of learning, practice and feedback schedules
· Stages of Motor Learning:
1) Early- Cognitive Stage: self problem solving, trial and error, visual reliance importance
2) Intermediate- Associative Stage: Proprioceptive(intrinsic feedback) importance, less variability and errors in performance
3) Late- Automatic/Autonomous Stage: movement consistent and error free, low attention needed-task performed automatically, can multi-task
· Feedback Schedules: Performance=Immediate FB // Learning=Delayed FB
o Immediate Post Response Feedback/Terminal Feedback: given immediately after each trial of the task
o Summary Feedback: given after a series of trials
· Practice:
o Massed: the amount of practice time in a trial > the amount of rest between trials. May lead to fatigue
o Distributed: the amount of rest between trials ≥ the amount of time for a trial.
o Constant: Practicing a skill at the same speed, the same set of skills each time the task is performed (better for performance)
o Variable: Practicing a skill at different speeds, and a different set of skills each time the task is performed. (better for learning)
o Whole training: teaching the task as a whole
o Part training: break down the task into steps prior to learning the entire task.
Breathing Exercises:
Facilitate Max. Chest Wall excursion in supine:
• decreasing the number of pillows under the head
• Place pectoral mm’s and intercostals on stretch- lay flat or with towel at thoracic spine or vertically spine
NDT and PNF Techniques:
PNF
o Rhythmic initiation (PROM>AAROM>AROM)
- used to teach pt movement pattern; take them thru pattern passively
- “Help me help you”
- actively w/ or w/o resistance