hysical
FIFTH
EDITION
eha biIitation
'11' considerable editorial assistance: to Alisa Yalan-Murphy, Faculty Liaison, Faculty Media Resource C~l1ter. Long hland University. for her great patience in l.:le~lting many high quality photographs: and to Ivaldo Costa \\ ho...e "tlppon has truly been immeasurable. Finally. \\e are grateful for the continuing strong and productiYe worling relationship that we maintain that has allowed u'> to complete a project of this scope through five edltion"l. Susan B. O'Sullivan Thomas J. Schmitz
vii
Table of Contents Section One: Introduction to Patient Care: Decision Making, Psychosocial Factors, and Values 1 Chapter 1: Clinical Decision Making
3
Su,an B. O·Sulli\an. PI. EdD
Chapter 2: Influence of Psychosocial Factors on Rehabilitation Pal Precm. OTR 'L.
~IS.
27
ABD
Chapter 3: Influence of Values on Patient Care: Foundation for Decision Making
65
Carol \1 Da- I'. PT. EdD. \15. FAPTA
Section Two: Examination Chapter 4: Vital Signs ThOll1
"...
Chapter
11
l):
81
DhD
f xamination of S".lcsory 1"unrtion
'> h
Tho"
79
121
T Ph D
Chapter 6: "
US(1~loskel"f.fH D
FxaJ"inaJlOn
159
Chapter 7: E"ammatiOl' ,}f(oordi .."tion
193
DJ-l't Th'",a
m
I'T F- D
Chapter 8: Examinalwn of Motor function: Motor Control and Motor Learning 227 Su" B l) S 1 a" P r ~ ID Chapter 9: Electromyography and Nerve Conduction Velocity Tests Lc ht:'
(J
273
Ponne) OPT PhD, f APTA
'>er~c
H Ro PT Sl D J"hn L [chllmacli P1 EdD.
res 1'\''-' \ Chapter 10: Examination of Gait { milla ( "'-lid Ill. P r EliD nh
l.lIntflhu(llllh
317
h. Sandra J Olne, HSL d' 6.:. UTI. ~lEJ, PhO
Chapter 11: Examination of Functional Status and Activity Level .nJrt:' , A
(JULllllflC
373
UPl PhD rAPIA
lJa ,d A Scailltlt P I ~1S
(J(
S
Chapter 12: Examination of the Environment
401
Illl,lIl,J J Sdllllllf PI I.JIII)
,
vi
Table OrConlenls
Section Three: Intervention Strategies for Rehabilitation Chapter 13: Strategies to Improve Motor Function
469
471
Susan B. O·Sullivan. PT. EdD
Chapter 14: Locomotor Training
523
Thomas J. Schmitz. PT. PhD
Chapter 15: Chronic Pulmonary Dysfunction
561
Julie Ann SlalT. PT. MS. CCS
Chapter 16: Heart Disease
589
Kate Grimes. DPT. MS. CCS
Chapter 17: Vascular, Lymphatic, and Integumentary Disorders
643
Deborah Graffis Kelly. PT. MSEd
Chapter 18: Stroke
705
Susan B. O·Sullivan. PT. EdD
Chapter 19: Multiple Sclerosis
777
Susan B. O·Sullivan. PT. EdD
Chapter 20: Amyotrophic Lateral
Sclerosi~
819
Van ina Dal Bello-Haas. BScPT. PhD
Chapter 21: Parkinson's Disease
853
Susan B. O·Sullivan. PT. EdD
Chapter 22: Traumatic Brain Injury
895
George D. Fulk. PT. PhD
Chapter 23: Traumatic Spinal Cord Injury
937
George D. Fulk. PT, PhD Thomas 1. Schmitz, PT, PhD Andrea L. Behrman, PT. PhD
Chapter 24: Vestibular Disorders
999
Michael C. Schubert, PT, PhD
Chapter 25: Amputation
1031
Bella J. May. PT. EdD, FAPTA
Chapter 26: Arthritis 1057 Andrew A. Guccione. DPT. PhD. FAPTA Marian A. Minor, PT. PhD
Chapter 27: Bums
1091
Reginald L. Richard, PT, MS R. SCOlt Ward, PT, PhD
Chapter 28: Chronic Pain
1117
Lisa Janice Cohen, PT. MS. OCS
Chapter 29: Cognitive and Perceptual Dysfunction Carolyn A.
1149
ns\\orth. OTR, PhD
Chapter 30: Neurogenic Disorders of Speech and Language Martha Taylor Samo, MA, MD (han)
1189
CHII'II'1(
LEARNING
OBJECTIVES
I. Define dlllll"J.1 reJ'oomng. What factor.. Impacl on (limcal deut Prat:tlce:'
any phy~ical manifestat1on~ that reveal emotional context. such a~ slumped body posture. grimacing facial cxpre~ ~ion. poor eye contact, and so forth. Finally. the inter\iiev. should be u~ed to estabh~h rappon. effecllve communication. and mutual trust. Patient cooperation ~erve~ to make the therapist's ob~ervations more valid Hnd become":. crucial to the success of any rehabilitation plan of care.
Systems Review The u~ of a brief screening eAaminatiun allows the Iherapl~t to quickly ~can the body systems and detennine area') of Intact function and dysfunction: cardiopulmonary. Integumentary. musculoo:..keletal. and neuromu"'l:ular. Information I":> also obtained about communltation , J.ftecl ,
cogllltion. ami learning ~tyle. Areas of deficit conftnn the need for further detailed e\aminalion b) a ph)sical therapi~t or referral to another health professional. Consultation with another phy\ical therapist i... appropriate if the needs of lhe patient/client are oll(~ide the scope of the expenise of the therapist a......igned to the case. Irthe deficit is outside the ,cope of ph),ical lherap). Ihen referral 10 another health care pro\'ider 1\ Il1dicated. Screening e\am~ are e.ldl."ut')
lnten Ie,", 4uestion~ de"lgned r) I(kl~dy em irOn'11CllLtJ l'l.)ndiu(lfl~ in '-I.hich patienl in your (,:arc (j,e .• Ba1>ic AC\l\· ItH:'i of D31I) LJ\ lllg l B AD L ~ 1. Insrrumental Acti \ it ies of DaIl) LIVing IIADL,jl" Who hdp~ you w ith the al'Il Vllies you want to do (i.t:. waJung . stairs. tran sfers),' Art' there aCliv itlt'\ yo u have diffic ult y with Lhal would bt'nefit from addlllOn.1i d.'i~ i !-> t,ln ublemem ri ..,k faLlon. lfldude Vvl1at pr()blem ~ might be iJnlicipated In the future " Wha.t can you du to dU111naie 01" reuuct:' the lihJl '
hood 01 thai happtlling" 0IJ.fl.:.d ~U fjfll 1" 1111 tht: Doc. UJ)It: lltclllun
l cmpliltl:
hll IJh }~luaJ
~ 1l.'r..trJ I PaUem/('!Jt:U1 M..uldgelllcill In till: (JIIIJt· /(J (J/nmu/ lht"lf'I.I/ I f Disabilit\': inability to perfonn or a limitation in the perfoml~lce of action~. task!>. and activities usually expected in specific social roles lhat are customary for the individual or expected for the pe~on's status or role in a specific sociocultural context and physical environment.
Categories of required roles are ~elf-care. home manage-
4 ment. work. (job/school/play), and communitylleisure. Disablement: an interaction/complex relatiomhip between the heahh condition and the cOIHextual factors (i.e., environmental and personal faclors),9 Disease: a pathological condjtion of the body or abnomlal emit) with a characteristic group of signs and symptoms affectinl! the body and with known or unknown etiology.4 Function: thoc;e activities identified by an individual as essential to ... uppor1 phy... ical, c;ociaL and psychological wellbeine: and to create a personal sense of meanil1gfullivmg. 4 functionallimilalion: the restrictIOn of the ability to perfonn. at the leve! of the \l, hole pet "on, a phY:-IC3J aCTion, task.. or aCtl\-II}, in an efficient. I)pically o:re...-terl. n~ competent manner. Health: "lale of comple'e: ph) ~ical. nl(,f'It:~ SIl~1: It:nn lrom II J (~uldt: IU PhY~ll ..1 I hcr"pJ~' Pr"UH._t;~ .md I_I Iht: Inlt:m.tllwlul (1 ..!>~i1lt"ll\)n (,I Impulrlllt:nh 1..11 .. bllllll: ,and li wllhin 6 .... eek ....
The follo,,"mg are examples of anticipaled goals \\ ilh variable lime frame,:
rt-Tenn Goal_ Tie patient Will increase strength in shoulder depre,sof mu ... · cia and elbo" ex.tensOf
..... aood to nonnal
mu~c1es in bOlh upper ex.lremities within 3 weeks.
fhe p;'ltH.·nt \\111 mLr~J"e RO\l Ii) dL;Tl't~' 111 I..ne~ C'\[en'hm hilalcfJII) I{I within nonllalllllllb \\lthlO ~ \\ed,. The p~llienl \\111 be IIlde~ndl'n[ III the appltL'atlLm l,t Itmer e\tremll) orthLl,e" \Hlhin I ~eek The patlenl and famil) \\ ill re.:ognile per'iLlOJ.1 and em Irl'nmental laclor, a.. . 'lXI:.1teJ \\ IIh tall, Junng amroulJtlOn '" Ithin ~ \l, eel,. The pauenl \\ ill attend 10 la,k hlr 5 mlO oul ot a :~ll mill lreatment ...e"ion \\ Ithm 3 \\eek,. Lon~-Tcnn GoaJ~
The patient \\ III inde~ndenll) perfonn tran,k ..... trom \\ heelchair to car \l, Ilhm .t \\ ed..... The pal lent \\ill ambulate \\lth bilateral KAFO, and l'rutehe, using a !oI\\ IO~Hhrough galt and do,e ... upen blon for 50 feet "'Ithin 5 \\eek>. The patient \\ ill mam[ain ,,>tatlL' balance 10 'ttlmg \\ Ith centered, s) mmetrical \\ eight·bearing and no upper e\[remlt~ support or 10.. 5 of balance for up 10 5 minule, \\ Ilhm 4 "'eek... The patient will 'equence :.1 three· 10 fi\e-'tep rouflne !ask \\ollh mmimum assi,lance \\Ithin 5 ~eek,
Chapter 1 Clinical Decision Making program~ (HEP]). returning to work (ergonomic training),
Th e Three Componenls of physical Therapy Intervention Coordination, Communication, Documentation
Patient! Client-Related Instruction
>--
or resuming social activitie~ in the community. It is important to document what wa~ taught. who was trained. and \\ hen the trail1lng occurred. 22
Procedural Interventions
>--
I
r
Procedural Interventions
Therapeutic exercise FuncllOnai training in self-care and home management. Including activities of daily living (ADL) and Instrumental act,vllies of daily living (IADL) Functional training in work (job'schooI1play), community, and leisure integration or reintegration. including IADL, work hardening. and work conditioning Manual therapy techntques, Including mobilizatIOn/manipulation PrescriptIOn, application, and, as appropriate. fabrication of devices and eqUipment (assistive, adaptive. orthotic, protective. supportive. or prosthetic) Allway clearance techniques lfltegumentary repaIr and protective techmques Elect~Gt."ler dalaba"le 1101.." to all a"pect of ESP l:Tllical appral"laIIOol"l (CATS> LK·ba..ed Cenlre for EBM 5ackell"" EB.\-l book. phy~iotherapy car.e~ gUldelme.. tor conductmg good RCT~ ERIC re~ource on meta.analy':ll'l
time (e.g.. stroke) and infonnauon about cltmcal outcomes is provided. No control or comparison group is used. Lc\'cl 5 studies include research based on expert opinion without explicit critical appraisal. While RCT provides the most rigorous design. there are times when the other de\igns are indicated. For example, there may be ethical ",>ue... involving control groups that receive no treatment \\ hen treatment is clearly beneficial. Or when outcomes are not clearly understood or defined (e.g., quality of life i..... uesL designs such as singe-case studies may be indicat"d. ~ec Table 1.1 for EBP: Levels of Evidence and Grades ot Recommendation. Cntical Appraisal Tools (CATs) are available to assist ill:' lnC"xperienced clinician in the evaluation of research '.g JI1 Law's E\'idence-Based Rehabilitation, Appendix "0 '. end Hele"a and Walker's Critical Emil/arion of Itt \ an h in Ph.Hieal Rehabilitation. Appendix ll'~L ('IHl'l..'IJ,IlS abo need [Q utilize effective strategies to ) }! mze and ...tore the data and to update data on a regular ba"'i .... Reference management sys(ems such a~ E:ndnote and Reference Manager (151 ResearchSoft, 800 Jones Street. Berkeley. CA 94710) are available to assist the therapISt. Evidence-based clinical practice guidelines (EBCPGs) are detined by the Institute of Medicine as systematically developed swtemems [Q assbt practilioner and patient deci ... ion~ about appropriate health care for speCific clinical circum...tances. 'W The) are developed through a combination of (I) e\.pert con~cn~us (e.g.. the Guide to Ph) ~Ical Therapl')l Prac(ice~); (:!) systematic re\ ie\H and mcta-anal)~i~; and (3) anal) ~i~ of patiem preferences combined \\/,U..:II\.lt) 1L'\c1 \0l.1;.\1 hl ...l0l). 11\ IIlg t"1l\ ifl,)nmcill. ...ou.tl/ht:ahh h,lhlt l'lITHI) health hl... ll.lI). and emplll) lTIl'nt ...tat1I ... , I h..' p.ll It..' II t goal... alld pnor IL· ... pOlh..~ 10 IrC'.Hmclll
o
Ph
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.,
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O/J)(( Till fl1ltl",~\ (Ol Jrl.' "h.lI Ihl. thl!" IpJ t ph ('n te ..."'. (11 meJ ... urc .... Tht' ll1/(ml1i.lIIPI1 '''' t~p'l,dh nrg.tJ1Jlcd b) ... peclfic he.ldJl1g'" b.l ... c.:-d nn II) hod\ ... ~ ... klll .... (t.'.1.!. lllll cuJo... k.e IctJ I. lleurnl11u"'lul JI 1..\1 d I npUllllnll.l1"\ 111 It' ~ u 1l1t.: 11 tar)): (~) I)pe ... nl "'pl.'lIlh. h: I .1l1d I11l',l url.'menl rl.'f lomled (c.g .. b.ll.1I11.:t' lc.:- ... I . g,lIl It: ........ RO\l Il' I . Irl·J1l.!.lh): and (.11 arca... 01 the bnd) ,IIlJ funL'IH'Il.l1 ...k.1I1 (('.~. \OL • upper c'\trcmllle... fL-E ... ]. !l)\\cr l·\tn:mltle... [I F"'l. 11 llnh. I. Objecti\"c IIlfonnation Illll ... 1 he ... Ialed III ll1t'a ... urahk lalll .... Ant \\/1/01t ( ~ l mclude ... protc...... lt.lIlal iud~l1lenl Ihput the ... ub.1e(,:li\c and/or oblel'tl\e fillt.!Ing .... ~ rnnfltlzl:t.! rl ) lem lI ... t i... generaled \\ 1Ih IInpaimlel1h IInk.t'd It) 'UI14..t11n.u IimitatlOl,.... The phy"'lCal therar~ dlagn{h\ ... I dCkrll 1ll\;J. u'-ling the Preferred Practlcc Pattern (... ec \ppcndi\ ) Plun (P) include... anticipated goal anu t:\pcl'Ied nUll )1111.. and autline'l the planned II1lel\ enllOlh 10 l"lt: u cd, Inl( \Im HI '11 ~hould be pro\ided conceming the frequene fX'l f 111 \'entian". treatment progre...... lOll. equlpmenl Ic.:-qlurcu '.lJld l\\ it will be used. and educallon lmtcgle.... Th4..' pl.111 aJ n tkx ments referrab to other profc ~ional ... and reCOIllJl1Cndi.IIWn for future inlervention!o. or follow-up care .... l
nlz
r
r
u ,II ... pu.U ' 1
eIn t
Cognith·e Proce sing lyles The
Clinical Decision Making: Expert versus Novice Jensen et al provide an excellent o\en ie\\ of the c\ idence accumulating on experti"e In ph~ "Ical therap) praclIce .-t~ The authors suggest that the knov..ledge. "k.ilb. and decision-making abilitie~ u~ed by expert clinician... can be identified, nurtured, and taught. Embrey et al-.\' ... ugge~1 that novices may benefit from a period of aClive menlonng b) expert clinicians early in clinical practice. Thi ... infonnalion has important Implications for novice therapl\h and for educators involved in teaching clinical deci..,ion mal..lIlg.
Knowledge Base and Experience Decision making is influenced by l..nO\.... ledge and experience. Experts ha\-e more knm\ledge and experience and are able to organize, integrate. and ... hape infonnalion Into a usable fonnat. Their I itnd IP a'lI li, \', hen the\_ did nl~t h..noiA .... UlTIrthin'-' . o· ' ': l
Communication and Teaching Skills Expert cllllician... were able to ITIdintain fucu ... on the patient a e\ idenced In their \ ('rbal and nomerbal communIcatIOn The)- \\ere able to pnwide hand ...-on examll1iltion and treatment \', hile lIlteracling ~ocially with their patients. Their ... mooth Interplay was re ... pon...ive to Ihe need~ of each mdl\ ldual patient and demolhtrated commitment and car-
Questions 1. De...cribe the key Mep~
for 111
MaIIiIItI
ing about the patient. Conversely, novice therapists were more structured by the demands of completing evaJuatjogs or interventions. Their focus was more on the mechanics of treatment rather than on the psychosocial needs of the patient.,0.47 Pediatric expert clinicians were able to consistently end each therapy session with a positive activity. frequently chosen by the children. Strong emotional bonding was evident. Novice pediatric therapists were less consistent in attention to the psychosocial needs of their patients. Expert clinicians affinned the importance of teaching in assisting patients to assume control over their own heallh care. In an era of cost containment and limited services. this is an important value and one that is essential for ensuring successful long-term outcomes. Novice therapists, on the other hand, demonstrated greater interest in mastering hands-on skills and in ensuring the success of their treatments. 45
Summary An organized process of clinical decision making allows the therapist to systematically plan effective treatments. The steps identified in the patient/client management proce" are: (I) examine the patient, and collect data through history. systems review, and tests and measures: (2) evaluate the data and identify problems; (3) determine the dtagno,is: (4) determine the prognosis and plan of care' (5) Implement the plan of care; and (6) reexamine the patient and evaluate treatment outcomes. Patient panicipation in planning is essential in ensuring sllcce~~flll outcomes. Evidence-based practice allows the therapist to select interventions that can provide meaningful change in patient'S lives. Inherent to the therapist"s success in this process are an appropriate knowledge base and experience. cognitive processing strategies, self-monitoring :'ltTategies, and communication and teaching skills. Documentation is an essential requirement for effective communication among the rehabilitation team members and for timely reimbursement of services.
Review
patiel1l/client managcmenl.
2. Differentiate between impairments, functional limilalions, and disability. Define and give an example 01 each. 3. What are the essential element ... 01' goal and outcome statements? Wrile two examples of each. 4. In evaluallng treatment outcome:..., why might a patient fall 10 reach the staled outcome'? What are possible
risk factors for disablement? What are the possible buffers? 5. Select a research ~!Udy and critically review it in tern), of Ihe e ......ential sleps of evidence-ba~ed practice. 6. What are the tOllr component' of the SOAP fom,at of written documentation?
22
Phyoical Rehabilitation
t u d y
PRESENT HISTORY The patient is a 7X-year-old \\oman \\ho tripped regarding potential
10
Ill. \1)/.'
di~able
ment ri~k factor~? 4. \Vhat i~ her rehabilitation prognosis? 5. Write t\\rn I Impaned \111lnr fundvlI1. \lu ... (k Pertunnalll..l;' Kange 01 \1011011. li,lit. Ll.K 'nH>l1I111 I Balance A...... llllIlh?1l1 i.\Ill! Sl'ar Fl)1l11i.HIOn P.lflt"11
J Imp,llred
\\ Illl ~"'Ill
lrlltogul111'nl.t1) InlL"gnt)\'.. . tXIi.HeJ
CH,·\PTER
2 LEARNING OBJECTIVES I. Recognize the p,»chO,\OI.:lallaclor-. Ihal mflu· ence rehabllll3tlon 2. Recogmze the Impaci of p...ychological funclionm2 and ...ocial IIlteracllon on health. dl\-
ea...e. ;ccident pronenes.... and adjustment 10 dine ...... and phy ... ical [muma. . 3. Recognize the p,>ychological tnlpaCI of dlSabJlII) on the patient
.... Be aware of different profe!>~lonals (and '[heir roles) to which phy"ical thera.pi'I'" can re er pJlienh \\ Ith p... yt:ho..oclall ..... ue... 5. Be aware or the joleneotlOo'" u'ied 10 handle chalJengJn2 beha\ ior-hovo to dee...calate an 32ltated patient. manage \ iolent pauenb. and identity "'gm of hyper\c\ualil). 6. Identl~ the stage", of P') \"'ho'l,.xial adaptation to 10.... and di .. abili~. 7. L'ndef',land the difference bet\\cen p...)chosocial adaptation and p... ~ cho..ocial adJu...tmenl 8. L'nderstand different ("oping: ...trategk... that ha\e been found to ~ imronant In p.. ychosocial adaptation and Jdju..,lInl'nt In chroniL: di
lX
11 Al1'.I1.1.1 ~,' \11\1'_ ) .H:t: 'habdll.l illn W P_m tL'.j" 1 .... .\n' .~l\ -Hl \\ tlP'n h.) \1~jV Rekn,il
1 ltI ...,,:..
It..:
'}
~
-! 'i
iJepll.:"ion amI Rdl..lhililatll11l 46 rre..lllll~ Pallent .. \~ ilh Depre ...\IOn 46 \\ h.,.. n hl '\1;ll.(' oual f:.u.:tor-, art;; nllm~roU\, J' OJ per\on'!'> p~)lhe I... atteLied b) countle~~ C'\cnh In
tht Internal and external em lronmenh. Thl\ lhal1teT ltK.:u~e~ on Ihe p,))lho\oual IJlIllf\ thai Il1tlul'nn~' the diretiion ot ph)\lc.:al the rap) IJ1I1:f\cnIIOn SOIllt: 11')cho~oclal hl
Sugge,uon\ for RehabilitatIve In(e ..... ..:otlon 53 Opllmizmg Paliem I",oh ement 54 l\e of Jargon and Labels 56 Rehabilitation Team \Iembe~' elf· Awarene..... 56 Summa~
56
motivation, family, social supports, life role . . , and educational le\'l:~l. All of the~e factors can affect pati~nh and treatment outcome..... Thi\ l:hapter (I) identitic... and de . . cribes ho\\ p.. . ) rho,ot:lal Ii.R·tor... GIn Intluent:c reh..tbihtatlOn: l::!) demon ...rr..ue, hO\\ to addre .......... u(h L.tt'tor, dunng ph) ... ical therap) Intcr\(;'n1l0n: and lJ) prO\ Ide\ Il1dil.,;,nion... for referral to P')l·ho...tll.·lal rehabilitation \pel.·lall ...h, P.. . )I..·ho~o4" . ii.tl faclor prolullru.lI) "Ilku a p'lIlt"OI·' abilit) (Q reco\er. Patienh \\ho are emotlon,tll) up.. . et \\111 hi.t\t" dlftlcult) conn:ntrat109 011 I1h) \lI.'al Ihemp) goal ... until C'motional I.......ue . . are
28
PhY'iicaJ Rehabilitation
addresscd If a palicnl I' mOllv,-ltcd to p~.IIIKlpate 111 rehabilitation. bUI hi ... or her tamll) member... uo nol ... upport the patten"s rehabllilatlon goals. Ihe pallenl \.,,111 he unltkely In progres... upon returning home, Mental he"hh status ha ... been shown 10 be one 01 Ihe mo ...' Importanl predictor... 01 phy~ical heaILh:'! Wickrama'iekcr" et al Immd that morc than 50 percent of all vi))il'i 10 primary care dOdO!'" ill\"ol\'ed somatic complaints resulting from p",ychoso2h ot ,\-'llIll1 plla"t' (h.' pa[J~nt " 111. ph~..,ical thaapl ... h need to be a\"~l1e of cal h patient .... p,,:chologlcal need .... During tlw IIlltl. feelmg'. or "~liol1\ Ihal up,el Ihe pJUent.
ThL'
fr.
IIclp-Rcjeclin/.l The pal lent de,,].., WIth the ... tre'... of ha\ Ing l'l}\ert hOqlle feding... loward caregl ...er... by fn:4uentl) aS~Jllg lor help ;lno thl..'n rejectmg every "ugge~lion. Workmf!, \\ lth a pallenl \\110 u..e' help.rejecting a... a dekn.,e mechalllsm I:an be \er) fnl ...tr3lmg Such palienl'l ...eem 10 .... l1l.:erel) ...eek help but reJt'ct all iu.h (("t" as meflectual In the...e case .... It rna) be helplul to pamt oul to the patient thai effort-. 10 help hale been th\\.\ned. The patlenl i'l usuall) nOI .mare Ihat he or .. he ha... rt'It'l:led all ..olutll1ll' and may Ihen come up \\ Ilil ,I ...olution or be more open 10 olle thaI !las already been proptl...ed.
Humur Humor .... luJ ... lIUitiIOIl For 1Il,I.1nl:t".
Chapter 2 Influence of P ychosocial Factors on Rehabilitation
Box 2.2
37
(colllillued)
a pallen I ... IJh.'''' thai he I'" gOIng 10 open UP;I hardware \Iore .. mLC he ha .. "'0 nlUf.:h hard\\are (meanlng \urgle,llIy placed pm .. and plait") m hI' Iq;_ A pallcnl \\ho u,e ... humor a....1 dekn ..e mCl.:hanl\11l u,u.llI) feel, ~tter If the ph)slcallherapI ... 1 l.lUgh, at 111' or her J0l-.e... and partlopates 11l Jo"'mg hcha\lor. It 1\ a ,afc v.a)' lor Ihe pallcnt 10 rceoglllzc the dlrficully
lIlg......ueh a, anger. but expre" ..e ... them by projecting them onlO another per"ion. rcmammg relatively guilt free. For example. a pallenl ...ays that h.... thcrapl'lt '" annoyed with him when III fact the pallen I i~ annoyed ""'llh his therapl~t.
of 1m or her '1lluallon
A pallent uses elaborate explanalions 10 reaS'lure him that his
Idcalization A patient cndo\\ ... another mdl\ Idual "ith 0\ erl) posItive at1nbule .. 10 enhance an otherwl ...e negall'.:e \llUallon. 1111'1 other lIldl\'idual nUl) be the therapl'l. In which ca\e the IherapeUIK relation .. hlp i... often '1trenglhencd. Or. II could be a "JX)u e. in "hKh cal;e problem ... could an ..e If he or she IS not ..ueh a po.. l1l\ e ..upport 10 the palient. It i... Important to uncover Ihe reality 01 Ihe ... lIuatlon so nece ...saf) Ireatment and di!'>-
IntellcctuaIization A pauenl u"e inlelleclual rea...olllng rather than expressing
emotion in order to 3\01d painful feeling. For example. the patient de..cnhc.. neurolra.n...millt'r... and ... ~nap ...e... when 'l"iked aboul a head inJuf). Therapi"itt IS insen\itive and doesn't under"itand her need~. The patient rna)' expres ... that onl} the po... iti\ely identified therapi,1 under,tand ... her problem~, Ho\\e\er, "hen Ihe PO,",II\e1) Identi!ied thempl"it 31,0 d~nte the patient' reque..... the pall~nt then \ ilifle, th.tt therapl ...t 3':> well The Iher.ipisl may help the p;ult~n[ (Q integrate the oppo... ite pole ... of his or her emotioll\ by bringing both pO'lili\t' Jnd ncg3li\e emotion, mto Io.:'lHhCiolhne,, _ The patlt:nt tht:n nl.t~ bt' .Ihle Il) ...ce Ihe reallt) 01 his or her ltu3110n
Prc.jcction
SuhlimatifHl
A pallt:nt ITan ftr hi ur her o"n unaueplablc= kdmg .... thoughts and belief mlo anulher rxr on and ht:cumt:~ It'nalll that the other l)Crwn reall) leel thlllt and ~h \es that \Ioa\ A p'.sU l cann t tol rale th Idea of ha~ mg unalo;C pl.thl Icel
Suhlimalion tlllUr, emultun or lJ.. 1ft: pk .1 p.tt!clU \\hlJ I unahle to llill ",iou
mg" a
.. Iated
regardmg the
t:
11
en'
H CllH__
pc.! t
i
I
1l~
out mentioning .il _ kC'lt'1~ .05)
Small sample Size and boIh treatment groups contained cognitive therapy. Five more palienls relapsed In Ihe cognilive group Ihan the cognl' live plus antIdepressant group
Blackbum and Moomead .. 2000
Depressed Inonb,polar and nonpsychotlc) or dyslhymic outpalients 64°0 female, Mean age = 437
RandomIZed treatment-outcome sludy comparing two groups cognrlive Iherapy 'N = 22) ana antldepres· - jJ1! reatment Et!'f; npty! ne or dCITl p ~rnJr:~J 'I 2J
12.9 weeks of Iherapy or medlcabon In a hospital
21% of the cogmtlve Cognrlive Iherapy lor group became palienls wilh mild 10 moder· depressed again dunng a ale depreSSion should be 2'year period lollowing conSidered before referral to intervention vs 78% of a psychialrist tor antldepres· Ihe anlidepressanl sants group, a Slgnllicant (p < .05) difference
Miler et al 1985
Depr ;: ~j no. i;}IP and 'll lpS;'Ch(j II, ~ dys r.ymlC Ot.;l!:'.::!ler··... 739 It llale ~an age _" B
Rar" "'zed treat'l .,rlt 'utcOrflr!lldy r:ng lo"J1rlJL. ... "iI "1= J' 1.. i:'r'I Q t • ressant 1::3t, n IN = 17)
15 weeks 01 ther· apy or medication In a hospital
46% of the cogmtlve group became depressed again after a one·year period following intervention vs 82% 01 the anlidepressant group, a Significant (p < .05) difference
Cognrlive therapy lor patlenls with mild to moderate depression should be conSidered before referral to a psychiatrist for anlldepres· sants
Bowers~
Depressed (Mnblpo!ar and nonpsychotic) or dysthymIC oulpatlenls 80" female. Mean age 362
Ral'ldomized treatment-outcome study companng Iwo groups: cogm· live therapy (N ~ 101 and antldepres' sant treatment (N - 10)
42 weeks of ther· apy or medication In a hospital
20% of the cognitive group became depressed again after a I-year penod follOWing intervention vs 80~~ 01 the antidepressant group, a significant (p" .05) difference
Cogmtlve therapy lor patlenfs with mild to moder· ate depreSSion should be conSidered before referral 10 a psychiatnst for antldepres· sants
Palienls Wllh IN 2765) nortblpolar and nonpsychotic major depreSSion or dysthymia
78 conlrolled chmcal tnals Pre· and posnests of the Beck Depression Inventory, MetaanalySIS uSing Hedges and Olkm d"f-
Ranged from 4 to 793 weeks of therapy
Cognillve therapy was more effectIVe than antldepressanls (p 0.0001), no Intervention, and a group of mlscellaneous therapies (p 0.01). bul equal to behavlorallherapy
limitation: Between-tnal homogeneIty was not met for two groups. the mlscella· neous therapies and the placebo, so the comparison of cogmtlve therapy and Ihese groups should be made cauliousty
1990
Gloaguen et al n 1998
I
" J'f
P\jnte fir nd
1I:t1ll
ar
II
.\ (lua) "orJ,.. rt"feIT.tll..t.l1l
In
rtf d
n'. n • f
par Illh
Ix-I
t:
rtullfthl p.lll nt
n
n: ult 'fllm a 1.llI-. nl l1eU' '.In rl: lll/fI.e Of III nih:
1m
11\ memhLT"',
Acute Stress Disorder (ASD) and Posttraumatic Stress Disorder (PTSD) People \\ho ,",ere dl ... ahlt:d a, a rc ... uh 01 a 1I,IUllutil C'\~~nl (e.g .. a \. iolent lnme. abu'lC. an ,u..:l:ident a naturallh,a,lcr. or war) or individuab \\ho ha\L' \\ ilnc.."ed "'lIdl arc al rl'.. I-. for pO.\f(rl.1l1maric Hfl'\\ di.wrc/el" IPTSD) or ell life "'"t'" disorder (ASD). BOlh are \pet:ltIL lorm, or ... ub CI'.. 01 .tJ1\iet} di ...order.... The DWl.!no.Hic lind S"lal1\1ic til \fall/wI of Memal Dnorders differentiate ... bct\\ccn both JI\orl!er\ 111 terms of the duration of the Ji ... on!cr and It, ... YlllpIOm\ Acute stress disorder (ASD) Jmol\'t~\ \)lllplOl1l ... that mu."t range in duration bct\\ccn 2 (Ja) ...
10
a
1lli.1\IIllUm
of ~
\\eeks. PTSD IS differentiated as anlll' PTSD II S) mptom ... last more Lhan but less than 3 months and as llmu1/( PTSD jf symptoms la..,l beyond 3 month.., ur longcr. Both ASD and PTSD. ho\\ever. must result from cxpm,ure to a traumatic e\t:nt. and PTSD can be qualified \\ ilh the tCI111
Chapter 2 Influence of Psychosocial Factors on Rehabilitation
abuse-may decrease. and a higher quality of life may
Box 2.5 Behavioral Features (Warning
ensue for the patient with PTSD.
Signs) of Possible Posttraumatic Stress Disorder (PTSD)
An~
(lne of the follo\\ mg beha\- 1(If'
• Recurrenl. mlru,iH recollection 01 traumatic event • Intru"'l\-e and di ...trc!'.... mg dream ... of e\-cn{ • DI ...... lXlatl\e ,tate (beha\ mg a If reh\ ing event: can fN "e\eral ...econd or mmute!'.) • Amne"'la of e\ents ~10re
than
Olle
Depression 1;1')1
of the fol1o\l. ing beha\ ior...:
• P... )t:hIC numbing (lad of intcre-.t in ... ocial or phy... ical enVIronment or acti",'ities; . . igl11ficantly lowered par1lcipalion in ...<XI.11 or phy .. ical em iromnent) .Cna/:lle 10 fcel emotion ... (e.g .• mtmlaC) love. ~e\ualitJ. anger!
• OI"'lUrhed ...leep pattern ... • H~pt'T\ Igtlan e • b.a!!,gen:l.led tartle re ron~ • Ongomg ,,~\ e of Imlahllu\ • Hel~hlened JIffil lit\. Yo uh con
ntr II n
Depre.nioll refers to feelings of despair and hopelessness. negative ",hifts in perception. and decreased interest III activitie~ that once provided pleasure. A person may have
a depressed personality (referred to as dysthymia) and therefore experience sadne~s throughout his or her entire life. A~ in 1110\t ca~es of depression, a person may have one or more cpi\odes of depression, before and after which a normal mood exist.lall1 P') cho\oclal wellne ...s. Any p:>.) chologlcal or ph~ ,u:al IInpamnent can dbrupt thi halance. In a ... Iud) of the relati()lI ... hlp bet\\cen dcpre ion and lel ...ure pat1icipatlOn In people with SCI. Lnv l~f ill found that patient\ \\ ithollt lkprl~ ... \ion had \\'Ider rcr,,:r· toire\ and higher le\el . . of h:·\.,un: 1 Therapi t Lan h('\p patlenl~ eIl2Y~~ I ll.... "t acti\ itie:... through the u c of Jlti\ il ~ 1I11.?re... t 'U1 \'e ~ .. J ,chedule.... A.ull. Human rCatllon ..., re'polhe pattern... , ..11lL! lhe ad" Med Rehabll 80:985. 1999 Kreuter, \1. et al: Partner relaliomhip" funclionlng. mood. and globalqualit} 01 Ii Ie in per...om \.\-ith ,pinal cord IOJury and traumatil.: brain inJury. Spinal Cord 36:252. 1999. Meara. J. el ill: U,e ollhe CDS-geriatric depre~sion ,cale a, a 'o(;reening tn ... trumenl for depre..... i\e \}mptomatolog) tn pJ.tienr... .... ith PJ..fkin\{1n·, di\ea-.e and their career... in the communil). Age .\geing 28: :\5. 1999. Dcnollel. J. Per-.onalil) ilnd coronaT) hean di,ea,e: Th~ I) pc·D '1.:.I.1e:-16. Ann Beha\ \led 2001:209. IWS ~~meroM. CB: The neurohlolog) of d~pre"ion. Sl.:i Am June:~2, 19~ pallentl> J ~ftecl DI'oOrd 49 ~q 19Q 78 Mayou. RA and Smith KA Po~nl'3umatlc !o\mptoms follOWIng medlcall1lne~s and lTeahllem. J Ps\chosom Res 41 121 1997 79 Bryanl RA. and HaJ"\Ie) AG AVOidant copmg Sf) Ie and PTS foI lowmg motor vehicle accidents Reha\ Res lber 33 631 1995 80 Herman Jl' Trauma and Recovery Basic Book ew Von. 1992. 81 Bartow DH Uoravebng dle my....... of ..""..y .... ilS~ from dle penpecbY< of emoaon II-,. hoi SS 124 82 Keane TM .... Bartow DH Pusnnumabc: Bartow DH cd Am"el)' .... hs DisonIen 0uiIf of their !lve,. among other act'. the> will probably l:hoo~e to I/o.ear a ~eat belt 'A-hlle dnvmg or ndmg m an
automobile That chOice 1\ guided b} the importance the} plac.:e on tht:Jr satet}. or b} theIr value of \atel}. Bel:dU"le \ alues are internal and difficult to mea\ure. Ihc:y have nOI been ~tudled a~ vJgorou~ly i.l\ Olher a~pect\ oj human behavior. One {;annot ~ee a value; one can only leel it workJl1g Value~ playa panitularly Ilnponant role In lIl11 u t:ncing our c.:holl:e~" The ImpOl1al1(;e ot lhi\ Intluenn: I empha Ilt:d I/o. hen one (';(1O\lder~ that J,,"IJH 1fI~ the nght Ihlllg to tlo i.1l1d dOlflg II art:' t"O sl:parale pht.:llomt:na. 1 he
vef'iU.,."..
Acting cool or aloof. obviously paYing more attention to other patients
1 a PreJudice. to prejudge or to classify a pArson as belong Ing to a larger group and thus to bellAve things aboul that person that one believed about thA larger group b Indifference lack of Interest or cono:>rn aloofness detachment.
2. Overty cntlclzlng you (the patient) so that you feel as If nothing you do IS nght.
2. a. Prejudice. b. Perfectionism: the doctnne that the perfection of mOral character IS a person's highest good and that freedom from Imperfection IS attainable. c. Lack of fleXibility
3. Treating you as an Object rather than as a person with feelings of pain. worry. and msecunty.
3 Depersonalization: to detract from an IndlVld, a's uniqueness: to fail to honor a person's Individuality
4. Treating you as if you were a child, incapable of really understanding anything that is said.
4. Patronizing: to adopt an air
5. Being unable or unwilling to help you In your exercises; leaving you alone most of the time.
5 a. Indifference b. Prejudice.
6. Making fun of you in your presence and behind your back.
6. Depersonalization.
t')
cen escensl r
7. Telling others things you have shared in confidence. 8. Not letting you work on your own. 9. More otten than not guessing about what IS best for you. Admitting he or she "is not sure" what to do. but "let us not let that stop us" 1O. Always fitting you in as if everything else in the therapist's life is more Important than you are.
10. PlaCing self-interest over patient's needs
Value-Laden Situations in Rehabilitation What would you do, and why. il thi~ ~itualion happened 10 you? Joyce. a 22-year-old college qudent, \\'a~ referred to ph~~lcallherapy following surgical removal of her left leg owmg to o'.>teogenlc sarcoma. Gther than generalized weakne~~ from chemotherapy, surgery. and bed rC\1 and mCI\lonal pam and \orene~s....he \\1e,lIn n A ... 'hum,IIl" .t... thl ... "hllin' 111.\~ t'em. mort' mature ~h.t\ u)r I required III ht",tlth prot,· 1\.)11.\) • II Ilmg r IlIJ\ \\e L1.t111l Iht' Iu lit ~ 01.1 plllll.lIlt;llll\ llull:lur I, tor Ih
72
Ph ic I Rchahilitalion
Impa,:t t,t thl thl·r~lpl'..1 nutbur'l r.ll"l'I) nl\C's \.du n,t ul prnttlcm, ~Uld lllIC!1 creal\?, l,lrpCI Olll". OhVHlU\l) th1' I not l(lndul..1\c tn ht:a!Jng On retkCllOn. l'l1l re,lllll'S Ih.1t J(l lC regn: I e beha\ 101' ma) IIkcl) rC\l.tl lIlnCT lontllll.. dr and/or derre"lOn. From Jo)'(('\ POllH 01 VIC""', It I' not dltlllUIt t('l come' III ,ome under,tandll1g thai a pL'r nn undu lhc'e clrcum,tance, micht N- afraid and T11Ighl "ce a ,lfer l. i,· ten,-'e In a \\ heekhalr Stopplllg to breathe. and then al till!,! on the \alue 01 compa"ion. ,u,tallled hy empalh\ and ,elf-tran"po,al. ele\ate, the problem-,ol\'lng prncc"" from rUll11011 to a I'rOfCS.\101WI l/wie c to 'It do\\ n and to dl'eu ..., thi, ""ue comprehen'l\el) \\lth Jo)ce, referring her
-
-
to the ,oclal \\or"er for P') chologlcal ,upport and l', had no moral obligations to their clients. the patients, \1Jnaged care 1\ a bu.,ines" onl). ln the eyes of the la"" 1CO do not practice health care. The primary dut) of the ht.:alth care profe lOna1 i" al\"3) " to the patient. and secondanl~ to the bu me" h a practice of your own. and have spent cOIl'iiderable time cuhivating referral... from local ort.hopedists. Unfortunately. your pmctice i... still in the red. and you have not been able 10 pay your'ielf a salary. yet. Managed care has shifted your referral ba~ to more pnmary care phYllician'i who hesitate to refer for specialty care. One patient, for whom you crealed a wrisl and hand ,plilli. begin!o> 10 regam funcllon sooner Ihan expecled. You call the refernng phySician. an orthopedist \"ho refer!. m01l1 of your pallenls 10 you, to II1form hlln Ihat you need to remove Ihe ~pllnt, becau~e il IS aClually hindering Ihe healing proce ...\. The phy\ician 1\ on vaca~
lion. and you are unable to rCilch hi ... colleague cmenng for him. So after a thorough e\.ammalion. ~ou Temme' the "plmt. give the pallCI11 precl..,c 1Il..,lru(t10n... fllr i.l home excrcise program. and as"- the pallenl [Q return for ph) ... icallherapy Ihree time" l\ and di\ i..ion of re~ponsiblllt)' in physical ,·rap). Ph)" Ther 51::!3. 1971 I-'d1t'plno ED. Pef'onal communication. March. 1995. h Ue."rin,) ED. and Toma~ma. DC: A Philo~ophical Ba~i~ of lieal Pradice. Oxford Univer.. it)' Press. New York. 1981.
Sl;:J)
h blJ
_~·pirat Ion 108
Korot~off" Sound.. 113
Age 96 (lender %
Slle~
IIf,
'\1unilonng \ncnal Rlf14,,,-1 Pr...."un: 1I)l) Blood Pre,,~ure Regul3110n 109 Factor\ Innuencing Blood Pre~sure 109 Equipment Requirements III
Rale Q5
Pul...e
m~ ~~'''rlrJlhln
The RC\PlfaIOry S>".. lem 103 Inspiration 105 t.'lgn.llt addressed 10 greater detail later in the chapter.
Table 4.1 Nonnative Vilal Signs Values by Age
Newborn
98.6-99.8
37-37.6
7(H90
25-50
S· 5(}-52 D: 25-30
3 yea,s
98.5-99.5
36.9-37.5
8(}-125
20-30
S: 78-114 D: 46-78
10 yea's
97.5-98.6
36.4-37
7(}-110
16-22
S· 90-120 D:5~4
16 yea,s
97.6-98.8
36.4-37.1
55-100
15-20
S: 104-120 D: 6Q-84
Adult
96.8-99.5
36-37.5
60-90
12-20
S: 95-119 D.6(}-79
Olde, Adult
96.5-975
35.9-36.3
60-90
15-22
S: 90-140 D 60-90
D
DtaSlohc; S ... SystolIC.
Adap1ed from Fitzgerald. MA," p.
WIth permIssIOn
Chap'er 4 '"al S;gn
Culture and Ethnicity A.. . \\ llh ~U1) ph) 'K:.II
Ihl:r.lp)
le..,1 ur ll1('a,urc. the mfluenL:C'
•
of cultUR' and clhnlllty on \'H31 \lp.n l1l~a,ur(' ... Cd11 ,a~ from
uhlle to J mJr.... ~d IInpau For c\arnple. a patient Y. ho ho.. lilc dunng e\allllllalulIl of \ 11.11 "go ... 11M'" l"l: llt infonllatJOn: however, when combined with datJ from vital ,,>Ign l11e~ures. II will provide importJnI dUl: tor directing lunher ~creenll1g and/or examinalton pnKcdure,. Le" I~ I offer~ the foHoy. ing general ,,>trategie... lO gUide the therapi,t\ ()b'er\iation~: • Sltl n \ of ImmedlJte patlem dl,tre~~ or di~omfort are t) plL"aJl) e\ idem b) oh,t::rvatioll of facial expre"'... lOn ....
u...c of ac(;c"ory rnu...de:-. for hrC:3thing. In irregular hr('alhll1g pallcm. J.nd freyuent flO'ltional t:h.lO~e~ Cluc~ aoout nutnllol1:l1 "talu.s. mJ) he lI1dlci.lIcd by obc~l1y or the pre,ence of cache'\ia. a ,late of III health. appearance of malmuflllOn. and wa ... ting a",ociatcu with man) chroniC di,ca",cs. Skll1 color changc" \\ ill indic~t1e If cyanosis i", pre~ent. Color change, in thc mucou ... mcmbranes ~Irc a\sociarctl with central c)anosis. Thc,c mcmbranes are normally pink and shll1) Irrems are impkmt:n1ed. II If,
monitors and aels to maintain temperature, tit:. ..ire'trll mal for normal cellular and \ t... ll'rgan fun.-tiflll Tfl~ th, r· moregulatory s}stem con~l~t' of three pnma~ UlIllPOneots: the thennore~eptor~, lile regulauug cenler. and the effector organs (Fig. 4.1).13--10
Thennoreceptors The thermoreceptor~ provide lOput to the temperature-regulating center localed in the hypothalamu:.. The regulating center i~ dependent on infonnatlon from Ih~r01or~ceptors to achieve constant temperatures. Once this informal ion reache~ the regulalor), center, it is compared \\ ith a "sel pomt" standard or optimal lemperalUre value. Oependll1g on the comraM bet\"een Ihe " and "')l1lptOllb of a 'e\er \ar) \\lIh the level of dl ...turbance o! the thlmnoregulalOf) cenler. Jnd \l, Jlh the ~pec..·llic stage of the fever (onset. l'llUr,e or lermmation), These ~Igns and ...) mptom... rna) IIldude gent'fiJl malal\e. headache. mcre;'l~ed puhe and rel:>plrat0f) raIl', chill~, piloerection, ...hi\'enng. 10l:>~ of appetllt: (anore\hl). pale ~km that later belome:-. Ilu ...hed and hOi to the louch.
87
From
Han::;e- MJ.
WIth permISSion
nallsca. IITIlabllll). t,· .. tle\.. ness. c'on tipation. s\\cating. Ihir.. t. coated wngue_ del.:fei.hed urinary output. \\eak.ne ...s. and lll'Ol1lOl,I, I' - \\-nh higher elc\ittlOn.. in temperature (hyp.:rp)rC\lal. disorient.Hum conlu.. ion. comubion... or cOllla may OI:UIr. These Ianer~) mpwm~ are more common III chtldn::n ) ounga than .5 year.. or age and are beile\'eu to he related w the Jlllmi.uurit) of th~ ncnous sy .. tem. Specific stage.. ha\'e hec:n identified describing the com..e 01 ,I kn:T • Till' pmdromal pllll.\{' IS the penod Ju ..t pnor 10 temperature ele\;,HuUl: non .. pectll~ ~)mptllms ma) be e\perienccd ~Udl ;,IS i.I .. light heaJa~hc. musde ... aches. general mahllse, Of 10..... 01 appetite • Imd\ioll or (1/1\t't I ... the penod lmm either gr..ldual or 'ouddcn n .. t: unlJl the ma\lmum lemperature Is reached; symptoms IIldude chJlh. hl\Cnng. and pale appearancl" of ...klll • Sttlti01ll1n phwl' V and ..uf· ficiem lather. vigorously nib Ihe palm" and dorsum of hand'i. Iingt:l3. and areas between finger". Imerlat.:e Ihe fingers and thumbs of hand~ during wa:-.hing. WJ'ih each hand for IS to 30 seconds using firm friction and a generous amount of soap. Carefully clean Lmder and around fingemaih a.''i Ihc\C sites frequently harbor nllcroorgJni~m~ A\oid contact with lhe sides of the sink during "J...htng Rinse foreanns and hands thoroughly leeping Ihe hands lower than the elbows. Dry hand~ thoroughly with a paper (olAel '" IIh fing:~r lip.. pointing doy.n. The hand......hould be dried v,lptng from the fing.er lipS toward the foreann. TIll'" technique minimizes the chance of recontammation of the cleaned area. Tum off the ,,".ner. [f a fOOl or knee pedal control 1:0. not aVaJlable. a clean paper tov.-el ..hould be u"eo 10 lum of! lhe faucet.
proximal button that releases the probe co\ er Jft~r temperature reading is complete). If one i\ U'iIJ1~ J small hand-held electronic unit. the tli"ltal end I" CO\· ered with a pla.!ltic shearh. 3. Ask patient 10 open his or her mouth. and pkll'~ the covered probe at the posterior base of the lOngue ttl the right or left of the frenulum in the subhnguJl pod-,ct. This placement po~ition... the lip 01 th~ thl'r' mometcr over superficial blood vessel... thal rdlt'd core bod) temperature. In...truct the pi.illcnt 10 dll>,( the lips (not teeth) around the Ih~mlOl1leter. Conllnul.'
oq
92
Ph, lIn,g a lrom the
the thermometer. dC. B. '~llh pennl .. ~ion.)
III
of blood through Ihe bod). The pulse c"" be palpated ,-,"here\cr a ~uperficJaI ancry can be ~labili7cd over a bony ~urfa III U'lC m m;J.n~ h~allh,,;~rt' t:llmg'l. for i.lddll1on~tl mlorrnatlCm on HR mOl1llOnng de\ ice'l. Ita reader is n:krrc-tI 10 rt:vi~" arlil.le~ by ALhlen anti Jeuto:ndrup auo llwJlerge anti Leger.. -\ number of ~tud Ie' h:t\e .d~o .uJelre .:d the iU:lur,tl:) 01 ",po:I.lfll HR!\h nl;llIUladUrl.:d b~ mOI\ uJu;J.1 ("("uranu.::>. .. M.ln) Ime~11 g..tlor ha\t' U cd eleLlrulardio~ldm ([eGI datit it" th~ ~old tand.lnt tOI Lomp..lJhOn "JIll ItR tlJtJ ohli.unc.:d tn III tlit' do: ICc: under Mud) In fl.; \ II:" 111)1 tht' IUt'I.lturc.: (Ill Hkl\1 It I IlllpnnarH to 1I01t' thdl 11111(1\ultJnt fre· lluenc) dlJ.nge cau~eJ by tht' mmt'mcnt alter... the pllL'h 01 the ,,"ound "aves a~ the~ are reflected back to the c\arnlner The change m pJllh heard by the e\.tmlller proVide ... lI11ponanlllltoml.llion about the bl()(.'J flov. thmugh a \e''lcl Sc~elal nllxlel'l of DLS unth .lre ..t\JtlJbl~ The c ......entt-II clemenh IIldud~ the ultra~olinJ unit. J hJ.ndhelJ prtlbe f pie loelt'urll.': U) ... ul) thai tr~m\mll~ and rl'L'C'I\ e ... "'(lund \\.t\C'" .UlJ e of both neural and chemical control and i... closely Integrated wllh the cardiova'icul:JT ",yslem. Breathing is conLrolled by the re'ipiratury center. which lies bilalerally m the pons and medulla. The respiralory muscle'i arc controlled b) motor nerves who~e cell bodie~ are located m this area. The re"'plratory center provides control of both the rate and the depth of breathing III respon ...e 10 the mctabohc nccd~ of Ihe body.:\~ Both ('e1l1ml and peripheral chemoreceplOfs mfluence re\plrttillng" C\PIL.llltlll I
\tuluple fa"h.lh \..olll .t1h:r 11I.11"111al 1t.·!",eJ, d1onk'~') n::"'pllallOI1, \ .. \\ Itll kmpa.IlUle ,tIld pul ..e. JJl) mtlu.... nce thJI IIh.-n':J~n till: nh:laholll.· r.ife .II,) \'\llIml:rc.l..e the rc.. . plrahiT) rail.' tRR). hkr.... J ..ed 1ll(,1.I~llJ.. m Jnd ,ub:\eyuenr
106 d~m~lnd
Pin ~l{'al Rehabilitation fllr ll\)gcn \\'111 \limulatl" lIlul"a\ed rC\pll'a110n
Comer"el) ...1" fl1clannIH: t.knwnJ" dllllinl"h. rC"ipirallOn" ;11 .. 0 ,\ III Jt.'lTea"e, Se\cral lI1f1ucm.'lflg tauor.. arl~ 01 parllcular rmp0rl.IIK'C ,\ hen c.\al1lming re"plratlon These Illdudc age. nod) "Ill". J as. regular or irrer:ular. The sO/ll1d of re~plration"l refer" to d~\ ..ilion.. tWill nor· mal. qUIet. efforlles... breathing. Although 'lome re"plr.uor. ~ound, are audible. Jccurate Idcntifii.'iltion re4ulrt'" JU"l'ul· tallon (Ibtening with a ~tethosl:oJlC plat.:cd dlret.:ll) .1gJm~1 the che~t \\lall)_ ~omlal (\C,il'ularJ breath ...oUJ1lh arc ht"lrJ pnmanly dunng inspiration :md "olJlld rdiltl\':" "ml,ll,\lh and .'loft.''; Common abnollnJI (~u.ht..'lltltlou") ,'''-lUnd'' (If breathing include: • \"hl'e:m~. which I' a COnlIl1Ui,lU\ \\lllI,tlll1l.': "llI11J pTll duced b) air pi.b"mg throul!h .1 n,trrowcd ~t1~\'I\ ,ul'h J' a brondll or bronchlole.~ l\ ollen l'oll1p~trcj III Iht'
Chapter" Vital Sigo.§ \\ hl ... tllllg produu~u \\ hen o,.,treh.:hmg Ihe nc,,:!.. of i.I h:llloon Jnd allo\\ I11g ~m tn C"'I.:.1PC ... 10\\ I) through the naITO\\cd pa"Jp.l·\\'I) 11 01.1) he heard on bulh l11,plr3110n Jnd explratlOll. but I' morc pronllnt:nl 011 C\plralioll. \\ hecllng I ' a common ...) mplOIl1 of aqhma. i, also ...cell In
CHF.•IIlU L:all re,ult lrom .1Il Jlrwa) ohqruction.
hJr,h. high-pItched crO\\ lilt! ,ound thai (x'Cur'" \\ nh upper Jln\ a) 01'htruc1l01h re ...ullmg in ll:lrfO\\ mg of the gloltl' or trachea It I'" apparent m patient"> \\ IIh trJdlt"al ...reno"'I' or pre..ence 01 :l foreign object Crackle... (JI ...o called raIn) are rattllllg or bubbling \ound~ that oeem 0\\ ing to ...ecrctions III lhe Jir pa:-.:-.age~ of the rc'plraIOI") Ir:lcl. The ,ound i... often compared to th,lI of ru ..tlmg a cellophant" bag. Crad.lcs ma) be heard \\ nh the ear but arc !TIo:-.1 Jccuralel) determined u... ing a 'lcthch(ope: appJrent III pallenl nclude ht"art failure urE::rr; a drug-,nduced respiratory cepresslOll and braIn damage (I"Dlca yon bolr, Sides ollhe CE;relJra' ~1E::misphE:re::. or d,enCE:phi;l.lunJ
Figure 4.21 '\llll11.d IIppltJfI,lluJ
OBSTRUCTIVE BREATHING
AtaXIC breathing IS charactenzed by unpredIctable Irregularity. Breaths may be shallow or deep. and stop for short periods Causes Include respiratory depreSSion and brain damage typically althe medullary level
Breathing punctuated by Irequent Sighs should alert you 10 the possibihty of hypervenlilalton syndrome-a common cause of dyspnea and diZZIness OCcasional SIghs are normal
In obstruchve lung disease, expirallon IS prolonged because 01 Increased airway resistance. If the respiratory rate Increases. the patieni lacks suHIClent time for full expIration The chest overexpands (air trapping) and breathing becomes more shallow
order. Apnea is the abse nce of re~pirat ion s and i ~ u~u:.J lI y tram it!llt. If \ U ~ tained for longe r than several minu tes. brain damage and death may occur. Bec;\Use rc:'!pi ration is under bolh voluntary (cortical) and involuntary control. it h importan t tha i the patient i:-.
un.m arc Ihal ft.>~p" .It lull '" bl!lI1~ t''I(amlncd Om:e il\\.ilIC nj the l'X.1I111 IKltIPIl. d l;lr;\( leri\ t1(" Ilj lht' hrcmhm¥ pm tl!m \\ III IIh'l} IX' alh~n:d Thi ... \. . il nnrl11.11 reatliOn to heine nh"'l·r\"t..'ll It 1\ 1~ll('n n::(:nlllJncndl'r! that re\plratlOn\ he obo.;ervcLl Illlml'dwtcl\ .l lier I;.tkmg the pul . . t:. After mt,"j. I(lrin~ the pul"c. the j Inger\ l an rel11<J11l In pklce .It Ih.: pul~e "Ile, .tntl rc"plraliOIl \ C~1I1 he mOnit ored wlthuut drilwmg th\:' pallell t·"lonsc.:illu", altcrllion to hl\ or her hreathmg pal" l("rn, Ideall}. rC"'pl ri.1I101l \hould he e\a01l1lcd \vlth the che,,! exposed , If thl\ i\ not pO ...... lble. or If respirations cannot t'Ie ea\ily ob\cr\eu through clothi ng, mallltalll linger... On the radial pule pres,>urc of -l0 mm Hg. BP IS a fUllCtlOn of two primary elements: (I) cardiac Outpul (amount 01 blood flow); and (2) periphaal rcsi",l+ ance (Impediment 10 bloud 110\1, within a ve.. . '>el) that thc heurt O1U.,1 mercome The relation,>hlp bc(\\een blood prt:,~ . . ure (BPI 01 tht' twO). ThL' \U,>UIllOIUf len!t'l I... IOJlIL:i.tll) ;tL:II\t' produCln~ a . . 10\\, l:olllinuJ.1 flrlng JrI JIl \;j thl'> . . 10\\. LOl\ll1IU.t1 hnng thaI malnldHl'" d pJrtlal "t"tll· ut l'unuucllon lIJ thl.: hlood \o,>d,> i.tnd pwnt!e':> 1l001ll"i \'t/wmofOI" 101/. III lhl.' ""'••1ll0Ior It'llll'r d~:o,I.,h JIl plO\ldlllg th\." "'Iahle art&:-
The dllloum of circulating blood in the body direc{l~ arft.:l.:h prc:-'>ure. Blood los,> (e.g .. he-morrhage) will cause pr~haped rubber 0< plaMic lubing thai joins to fonn a ""ingle lumen and Jllin:h the head distally (Fig. -1.2-1. lef,); or (2) IOsen ~parate rubber or plastic tube~ that do not .10m (Fig. .J.;.,J. righ,) and lead individually direc,ly '0 the dlJphragm (!he two lUbe, are held logelher "i'h ,mall me'al da,ps). There are two types of distal sen\lIlg ITIlcrophonr.. 1;\1\(1 ca~led !leal! or c!lesfpleCe) on ')tcthoscope\~ a hl'II-\I/f1pt (FIg. 4.25. left) and a[lUl dis/' diaphragm (Fig. -1.25. nghll Stelhoscope~ may have only one typc of head; olher.. hJ\t a combination design \'. ith one side bell-')ha~d and
'0
C Fig~ 4.23 Electronu.' ... phygmomanomeh~r .... (A) Ann cuff monl(or. (8) Ann cuff monllor wilh pnmer thai provlde~ a hard copy ~cord of blood pfl:..,ure and pul,e readmgs in eilher numencal or bar graph fomHH (e) WriSllllonilor. (Courte~ uf Ommn. Inc. Vernon Hoib. IL 60061.1 Y
m'O ,.0
w(
11 I
r F gure
SleI.hO"'COpe~. Slandard
acou!ltic ,tethoscopc \\ Ith a ,mgle tuhe Ieadmg 10 dli.1phr.tgm (left) and Sprague Rappaport !) pe ,telho"cope \"ith t\\ 0 "eparall~ IU~,) leading 10 diaphragm
gu
4 25 CombinaLion dt:sign stethoscope head with one side (left) to auscultale low·fn.'quency sounds and Ihe oppo~Ide a nal disk diaphragm (righr) for hlgh~frequency sounds.
bell-~haped ~ite
fnght).
other a flal d"•. The bell-shape amplilie, 10\\ -frequenc) \ounds 'uch as tho'le produced in blood vesseh and are generally recommended for detemlining BP. The flat di"k diaphragm I~ more useful for high-frequency sounds \uch a\ hean and lung soull(h. Anolher t) pc of '1ensor Illcorpo· rale... bOlh high- and 10\\ -frequenC) capabl1ilies of the IWO ~hapes mlo a ~mgle-\ided unil that eliminatc\ Ihe need 10 tum the head over. To hear low-frequency . . ounel (bell~ shape I. light pres\ure of the examlner's fingers IS used: firm prcy,ure allo\\o\.' m a ITIm IIlg •.IlnbulanL'e allov. ing Ihe paramedit' 10 hear Im\ bre;lth .md heart \Ound\ and to mOllltor BP DI pu i.lblt' \t~lh(hcopes Jre also J\ ailable for u...e III hl,gh-ri ...1. ...etllllg, \\here lllllHmi71ng the 11 ... 1. of cro... ~ IIlkctiulI h c.....,ential.
Korotkoff's Sounds When l1ll:usunng BP, ..I seric\ 01 ~oul1ds IS heard Ihrough
tht' sletho"'ound,. AnOlher I) pe or . . cnsor IIlcorpofate' bUlh hlgh- and lOlA-frequency capabilitie'> of the (\\otll1d (hcll...hape J. lIght prcv"ure 01 the e,\Jminer'" finger... i.. u...ed: firm pre.. . wre allow" high-frequency soumt.... to be heard. Ekctro01c (battery-powered) sfetho.. .cope\ (Fig. ·t26A) pro\ Ide hight'f kveb of ampllllcalion IAlth volume control, and dual-frequency sound fillcring: ...Ol11l' art: available \~ lth Jlltachangeahk relllm'dble hC~ld". A de"Jgn \:mation for prehu"pltdl L1l1ergL'IK) Medli.aJ Ser\'iu: (EMS, pcr..,onnd pro\ IJe~ hlghl:1 1 should be alert for the presence of an ausCUllal()r~' gap especially in patienb with BP above normal value:... (hypc:rtcn~ion). An au:...cullafory gap i~ the tcmporary dl . . appearancc of 'loLJl1d nonnally h~ard over the brachldl artery between phase I and 2 and may cover c. The) abo arc u~ed when upper c),.lremJl) prcfl
IW I ('mp
~111(",J ,. 1Wc: ..ure. l. medical hi'itory j"i unrclllarh.i.Jb!t' except for the usual childhood diseases. He had recentl} relocated 10 lhe area because oj a dt'slre to be a
competitive skier (an activity he has enjoyed all his life). He works as an accountant for a local investment timl.
ADMITTING DIAGNOSIS Hypothermia and froslblte of the toes. thumb, and index and middle finger,,;. bilaterally. Blood pressure: Systolic pressure i-: 45 mm F-lg; dia'itohc not per~cptible. Pulse: Decrea"ed rate. small. weak. carotid pube (12 bplll); peripheral pubes not perceptible. Respiralury rate: 6 brealh'i per mlllute; re~pir~uion~ barel} perccpllble. Temperature: 82- F (rectal). Cognilion: Dcpre~~ed. unre!-pOIlSlve. Oeep tcndon rel1e~es: Ab~l:nl.
118
l'h~ ..ical
Rehoth.lit:tlion
CutanfWU' ~en ~llion: l'nr~"Il(H1"I\I..' 10 .\11 ...en t'n
IOdudmg ram lntegument: \1~lrk('d "kIll l:olnr l..h,tn!!l..~'. him h ap~X"lTan(e of C'ilrlotx'". hp.... tlnger.... and trk.·...
,
\\h.t! "lluld
IlH.x1alilll' ....
~r"l~
In
the Inlen"I\\..' Care L:1lI1
referral h., ... Oecn made
III
ph\ ... 'C,ll
Ihcrap~
"'
(ICl l and a
rC4uc"'lng
l" 10
Il1nnl1flrJ
rill' I unl tUlIl III
the thaIllOfl..·.f!ulalo! \
u'nk'r
helomc,
"i..'I"HHI"ly IIllPdllCd "IK'n rod~ ICJl1rx-flopmellr and necwiol/
ofrht' hnllll .\jUI/I·"OI/.\.1 I'~' _.,4 Jeal/ Awn. PhD
TIlL human ~) ~te1l1 i~ cOl1lJnually lIlundutcd Wllh ,:>en,:>ofY mformatlon lrom a \ ariel}' of el1\ironmeJllal inpllt~ a~ \\ell d.... hom l1lo\.cment, touch. awarene,:>::. of the bod) In ~pace, !lIght l"uund, and ...meJl. "In all higher order motor behavi()r~.
13~
Screening 139 Preparation for Admini,>tering the Sen...ory E,;unin;.lfioll I~O Testing Environmenl 140 Equipment 140 Patient Preparation 141 The Sen~or) Examination J~I Superficial Sensations 142 Deep Sensalions 145 Combined Cortical Sensations 145
Reliability 147 Qu,lIllitalive Sen\or} Tc,>ting and Spel,:ialiled TIC",>fing In"lrumenb
I~S
Cranial NCT'C' Sneening 1:'\0 Sen"'1fy Inlegril) \\ ithin fhe ('cmll'\t TI(,.lIml"nt 1:i0
llt
Summar) l:i..:!
the brain must correlate sensory inputs with motor outputs to accurately assess and control the body'~ il1leraction with the ellvironl1lent:·~· p ~2 Sensory integration is the ability of the brain to organize. interpret. and u~e sensory infor~ malion. Thi::. integration provides an inlemJI repre::.enralion of the environment that inform" and guides motor respon~e~.2 These sensory repre::.entations provide the foundation on \.\ hieh motor programs for purposeful movement~ are planned. cooflljnated. and implemented. ~ Ayers defined scnwn)' IlIlegruflOlI as "the ncurologltaJ proces~ that organlle::. ~I,;"nsalion from one's own bod) and fromlhe environmenl and makes it possible 10 use [he botly effectivel) v. ilhin the em ironmenl:'~' p 11 In an intact ::.ystem. ~cn ...ur)' Integration occurs aUlOlllalicaJly without con...ciou... effort
122
Ph"llJical Rehabilitation
Sen",or") mtegration I'" a Ihcor) lkwlopcd h) A Jean A)'er~. ~1Il occupational thempiq v. h(l\e ",or\... locu ...ed on c\amining the manner ill \\ hich ...cn"ory inlcJ;rallon dt.:\'l'lop". Idenllf)ing patlelll... 01 d) ... funl'linll 111 dliidren \\lIh leam1l1g di"(mJen.. and dncloplOg Il1lcn.-enlum "tralegu:... to Ilnprme proce smg 01 ... en ...or) 1l110mlJtioll The theory purport ... that dl ordered ...en,or)" mlegr;lIlon dinxll) llnpaCh bolh lllOIOr and cognlli\c ICi1rllll1g and that mtcrvcnlion ... de... igned to enhance 'l('lhOI") integrl1tioll will imprO\c leaming. l Bund) and MlIlTay~ sugge'll the value of the theory hes 11111" ll ... crulne'~ 111: (I) c\pL.llning beha\.ior~ of IIldi\ Iduab \\ ith Impillred ...en ...ory iJ1lcgralion func· tion:-.. (2) ~~tabhshlllg a plan of care (POC) to addre pccific impaillll~nt... , and (3) predicling ('\pectcd outcome of the selected inter\'cntion ....
Sensation and Movement Motor Icaming and motor perfonmmce are inextricably linked to sensariol/. As a motor task is practiced. the individual learns to anticipate and correct or modify movements ba~ed on sensory input organized and integrated by the central nervous system (C S). The C S uses this infomlation to influence movement by both feedback and feedforward contra!. Feedback control uses sensory information received during rhe 1IJ00'emf!1If to monitor and adjust output. Feedforward control is a proactive strategy that uses sensory infonnation obtained from experience. Signals are ~ent in alb-once of nlO\'emellf allowing for anticipatory adjustment~ in postural control or movement. 3.6 The primary role of sensation in movement is to: (I) guide selection of motor responses for effective interaction wilh the environment and (2) adapt movements and shape motor programs through feedback for corrective action. Sensation abo provides the important function of protecting the organi\Jl1 from injury. See Chapler 8 for a more detailed discussion of C S control of motor function.
Sensory Integrity The teml sOInarmemarioll (~omatosensory) refer... to ~en sat ion received from the ~J....in and mllsclllo~keletall\)'steill (a" oppo~ed to Ih,11 1'1'0111 \pecialized ~en ...e ... ",uch a~ \ight or hearing). E~alllination of ...en"ory funl:tion llI'volvcs tC~llI1g ~en"ol) IIltegnty b) delcllllllling the patient ahilit) to interpret and discriminate among 1Ill:01ll1llg ...cn or) information. The ...clhOr) c\(' J.IlJ 111 a) indicl' example\. whidl are not all-ll1clu ... ivc. lIldicalC the \\ ide "pectrul1l of inJune\. di,ea\e. and pJ.tholo~ gll:\ Ihat may pn.',cnI \\ ith Ic' ~ bH\lL I\lrk. htHlle. g..lrdcnl. fht" tJ"'J... \.'.111 ~ nude Ilhlil' lh.tlknglll~ h~ lhll1g. plO~rc'",i\d) Itlllgl'r \\l'Irth Indl\ Ilhl.lI" \\ tIh .1 hl~h .l11l'l1lhlll "'p;1I1 \\-111 be' .tnk to per. l\lTllI Ihl l;t ... k \lklllhll1 Jl;.'lll1b \~ III lx' .IPI';Il('llt \\ hen tht." (lhkl III kltlT... 1... umtu ...cd I
Orient.llion Jl'kr~ tu tht' Pl·hOll. ,1I1d pl.h.\
rl.ltlc·l1t .....1\\.lfc'Ilt: ...... of tll11t.' . In Illt:tht.tl rl'n)rd d0l·UI11l'nt~HIlln the
128
Ph}sical Rehabilitation
Evidence Summary Box 5.2 Research Exploring Age-Related Changes in Sensory Function Reference
Purpose
Subjects/Design
Results
Conclusions/Comments
Stuart, et ai, '0 2003
To detennine if vibrotactjle sensibility of several skin surtaces deteriorated equally with advanced age.
Two groups of healthy adults, mean age 20.2 years and 68.6 years, respectively. Four skin sites (palmar surtace or Ihe tiP of the middle finger, volar sur· face of the foreann, lateral aspect of the shoulder, cheek caudal to the zygomatica) tested bilaterally for vibration detection thresholds at two fre· quencies (30 Hz and 200 Hz).
Slgmflcant differences were found between the young (N ~ 22) and old (N = 22) group. Thresholds were elevated in the old group for both frequency and site except at the fingertrp Similar effects were found within the old group (those aged 75.90 compared to those aged 65.74).
Confirms that vibration senSItivity decreases In the elderly The lack of Significant deterioration In the fingertips reflects tne Importance of thIs area In manlpulatmg and explonng the enwonment and the resultant plastICity In thiS area relallvely small sample sIze
Tran, et al,12 1997
To examine the effect ot aging on motion detection and perception.
46 visually nonnal (visual acuity 20/40) subjects aged 19-92 years. Motion detection was lested objectively via infrared ocuklgraphy and motion pelteplion was tested via subjects' use of a computer joystick.
Motion detection and per· ceplion both showed agerelated deterioration.
No relationship was found between detection and perception. suggesting that these two pathways are distinct Age-related detenoratJon of motion detectIOn and perception may be related to luncbon of these pathways. relabvely small sample size
Benjuya, et ai," 2004
To identily the shift to reliance on visual and somatosensory modalities that takes place during aging as a means for maintaining pastural stability.
Two groups of hea~hy subjects, one group containing 20 subjects, mean age 26.6 (young [y]), the other containing 32 with a mean age of 77.8 (old [0]). Subjects were tested using a force plate (center of pressure ICOPI, sway) and surtace EMG (dominant leg musculature). Balance was tested for 20 sec· onds under 4 conditions: (1) eyes open, wide base (EO, WB): (2) eyes closed (EC, WB); (3) EO, narrow base (NB): and (4) EC, NB.
Significant increases found in COP path, sway, and muscle contraction from Y to under condition 1. Consistently higher values for these data in the 0 group for condition 2. The 0 group signifICantly increased muscfe contractjon from EO to EC, but most did not have a significant increase in sway, as did group Y. Significant changes found in condition 3 from Y to 0 in sway and contraction. Similar changes found in condition 4.
Reduction of Visual Input had a greater impact on postural sway in Y group. EMG showed the 0 group used a soleus and tibialIS anterior co-contraction pallern to conlrol body sway. Older sublects exhibited a tendency to uhllze muscular contraction strategies rather than rely on sensory Input to conlrol postural sway: relahve~ small sample size.
Experiment 1: To detennine ~ (1) age dependency in bal· ance is greater with EO than with EC; (2) correlations of respiratory function are greater with EO; and (3) balance with EO shows greater sensitivity to physi· cal fitness training. Experiment 2: To detennine ~ (1) mini· mally Slghted
Experiment 1: One·year longitudinal study with two waves; 225 SUbjects, men and women aged 50 to 82 (mean 62.8) years. More than 50% of the sample participated In a fonnal exercise program (wave one, wave two, both) consisting of flexibility and endurance training. Balance on one leg was tested tor a maxi· mum of 60 seconds. Two meas· ures 01 respiratory function were laken as well (forced vital capacity, l·second forced expi· ratory volume).
Experiment 1: EO balance tests showed more age· dependent results than EC lests. EO tesl showed high relationships with respiratory function and Improved With exercise. EO tests found to be more reliable. Experiment 2: No significant relationship was found with respect 10 age. No significant difference was found between those born blind and those Wlth acqulled blindness.
EO balance tesls give more vahd Indicahon 01 nonnal postural control skills than EC tests postural control may Improve With fitness training. Balance skills are lower to subjects with blindness com· pared 10 those wilh some Sight. but bolh are significantly lower than skills seen in sighted sub· jects; large sample size used for data collection.
Slones, el al,17 1986
o
Chapter 5 Examination of Sensory Function
129
Evidence Summary Box 5.2 Evidence Summary: Research Exploring Age-Related Changes in Sensory Function «oodoo«l) Reference
Purpose
Subjects/Design
Results
Conclusions/Comments
sUbjects would have an advantage over blind subjects due to some visual input; and (2) test it balance is better in subjects who acquired blindness as opposed to those born blind.
Experiment 2: 22 sUbjects, either tully blind (15 subjects), or minimally sighted (7 subjects, maximum vision 20%). Ages ranged from 19 to 84 (mean 52.7). Balance was tested with the unipedal balance task.
Minimally sighted sUbjects had longer balance times than blind subjects.
ValentlJn. et al,16 2005
To examine the longitudinal relation· ship between sensory function and cognitive function after 6·year tollowup in the Maastricht Aging Study.
All participants recruited from the Maastricht Aging Study. 418 individuals (214 men. 204 women) aged 55 and older (mean 65.9). 27 received an intervention to improve sight or hearing. Cognitive measures included the Visual Verbal Learning Test, the Stroop Color Word Test, the Concept ShiNing Task, the Verbal Fluency Test, and the Letter-Digit Substitution Test. Sensory measures included: Visual acuity-Landolt·C optotype chart; Auditory acuity-pure tone aUditory thresholds.
A change in visual acuity was associated with change in most cognitive measures. Change in hear· ing acuity was associated with change in memory perlormance.
These results suggest strong con· nections between auditory and visual domains and cognitive per· formance. This supports the need 10 screen older individuals for sensory deficits so Ihat such deficits will nol be confused with cognitive problems; large sample size used for data collection.
Wells. et al,19 2003
To determine how much age affects plantar vibration sensation, and to find if these changes depend on frequency and location of the vibration.
12 participants, 6 in a young age group (mean age 26 years), 6 in an older age group (mean age 88 years 8 months). Vibrotactile thresholds were determined for 4 different frequencies at 55 locations at the footsole. Subjects were tested in an unloaded position (laying face down). Testing locations were divided inlo three groups according to threshold values (toes, arch/ball, lateral borderlheel) for purposes of comparison.
Acuity loss was found in elderly persons at frequencies of 50 Hz and higher. The greatest acuity loss was found in the lateral border/heel, followed by the arch/ball. then the toes.
More callused areas showed decreased sensitivity to vibrotactile sense, corroborating earlier investigations that suggest thick· ening of the skin leads to decreased reception. Decreased vibration sensation may have a detrimental effect on gail; relatively small sample size.
Hughes, et al,20 1996
To examine the relahonshlp 01 posIUISI sway to sensonmolor !mpalrment. functional performance, and selfreponed dlsabilfty
Cross·sectional cohon study of 100 community-dwelling elderly (mean age 77.2) unable 10 climb stairs step-over-slep. Postural sway (path length, area) was measured uSing a force platform, 2 trials EO, 2 tn· als EC lE strength was meas· ured at the plantarflexors, dorslflexors, knee flexors and extensors. and hip abductors. along
AU measures of postural sway were significantly positively correlated with tibIalis latency except EC path length. Area measures were signifIcantly posItively correlated WIth strength Indices Ankle ROM did not have an effect on results SUbjects With ImpaIred sen· satlon had greater sway
These findings suggest that pastural sway more likely provides a piclure of sensorimotor problems rather than functional abilities, However, thiS study cannot be generalized to all elderly patients, as all subjects were moderately funcliOnally Impaired, relatively large sample size used tor data collection.
(COIlt!Ou9(./1
Evidence Summary Box 5.2 Evidence Summary: Research Exploring Age-Related Changes in Sensory Function tcoo,;ou""l Reference
SubjetlS/Design
Results
with tIbialis anterior lalency after unexpected perturbation of support surface Ankle dorsIflexion ROM was measured. Ankle proprioceptJOn and VibratIon deleclion (tumng fork at head of first metatarsal) were measured. Functional performance was measured usmg functIonal reach, limed 10·m walk. chalf nse, Duke Functional Mobility Skills, and 6·minute walk. Disability was measured using the Falls EHicacy Scale and Ihe MOS-SF36.
wIth eyes closed. There was no correlatlOn between measures of sway and any measures olluncllonal performance. and very weak correlatIOns were present with measures of disabIlity
To collect data lrom a large cohort 01 the normal healthy pop. ulalJon and produce age related charts of normative data.
1365 healthy volunteers, range 8-91 years. VibratIOn perception threshold was measured btlaterally al the thumbs, great toes, and over medIal malleoli usrng a hand-held blotheslometer.
Age proved 10 be Ihe major determinant of Vibration thresholds.
These results agree /-11th pre"/IOUS studies that upper and 1()','ler extremitIes exhibIt a decrease In Vibration sensallon after the age of 50, large sample size useliler data collection
Prioli, et al,25 2005
To verily the cou· piing between visual information and body sway In active and sedentary elders.
48 participants were divided into three groups of 16: active elderly (AE), sedentary elderly (SE), and young adults (YA). Subjects were asked 10 malnlain stance In a moving room consIsting 01 three walts and a ceiling. The walls were covered With vertIcal stnpes. The room moved forward and backward either continuously (1.1 cm diSplacement. 0.69 cmlsec peak velocity) or dIScretely (2 sec. of displacement, 26 cm, 1.3 cmlsec).
While the visual manipulafion affected sway In all three groups, the results Indicated that Ihe coupling between visual Information and bocy sway was stronger for AE and SE SE swayed more than AE and VA under discrete condltlons.
Changes In elderly postural can· tral might not be due to Visual cues from the enVlfonmenl. but how these cues are Integrated In order to produce appropnate molor actiVity SE were more susceptlble to VIsual maOlpulauon. poSSIbly because they have preelems solVing a conflicting sensory SituatIon: relatively small sample size
Gustafson, et at." 2000
To evaluate the change In balance performance In aCWe healthy e!deny people In a follow up stUdy 7 years aHer 30 subjects partiCipated In a study to evaluate Ihe eHect 01 physi· caltramlng on balance
17 out of 30 onglnal subJects,
All sUbfects reported thell achvlty levels to be equal or less than that dUring the anginal sludy t t sublects reponed balance and verIrgo problems The group had SIgnificantly ImpaIred static balance results In 4 of 6 tests compared With the Original study (Sharpened Romberg). Time reqUIred to wal" 3Q-m had Increased SlgnrhcanUy Most dynamoc poslufOgraphy scores had nol changed slQnlflcantly (some MCT changes)
More dlHlcult stabc balance tests ISharpened Romberg. one·:egge of ~lInluh 10 olh..:r ~n'oOl} re....eplor.. \\111 be p,:r~"'I\..-J ~ pam. Adapl~d from Waxman. SG.'" GU)lon. AC..lOd HJ.ll. JE: 04 Fi[l~~·rJ1J. MJT. 7! and Frederic" ... C/vC 1
Chapler 5 Examinalion of Sensory Funclion
135
Hairy skin
Glabrous skin
_---if--
Meissner's corpuscles
r-::p't--
Free nerve endings
I'..~::;..~:::~~~o$~f~t~~~~~~i-=-==
Krause's end-bulbs Hair follicle endings
11-+-"'1--
Pacinian corpuscles
Dermis
:
Merkel's disks Ruffini endings
Figure 5.3 The CUlaneou\ .l>en... or) receptors and their rC"'I>cctivc locations wilhin the variou'> IJ~cr, oj '''Ill (t'rldcnnl\. denl1l\. and the '\uhcutaneou'l layer).
a gl\en bod) ,urfneC'. Figure 5.3 illll'ltrnte'l the
clltaneou~
... el1\or~ rel·eptor... and theIr re,pel.:ti"e locations within lhe \anou ... hi~('r, 01 ... ~in.
Free 'tnt Endings The-.e receptor... are lound throughollt Ihe hod). Slimulation ol/ree nl.. 'r\C endIng r~ ... ull in the perceplion of pain. temperature. tllulh. pre ure, 1Il'~Ic:. 111: :,,>ide and pJ'I'> up to tht' thalamu:"> Ihrough bllalcml pi.llll\\a)~ called the 11/('dial /('U/m.\cl. Eadl medldl lemnl'll'u"> lermlllalc:,,> in the \c::ntri.ll po"'teroIJlerallbJIi.llTIu.... From (he lhalalllu'). tlllrd-ord~r neuron ...
project to lhe .somatic sc::nsory cortex. Projection to :">cn.sory a" ...ociation areas in the cor(e~ allo\', s for the perception and interpretalion of the combined cortical 5en.satiul1'\ {Fig. 5.5).6\-(l~,cl(>.7'i Table 5.1 pre.sents a l:om-
column-medial lemniseal [rael carrying .')llch as kineslhc.!'>i:l and louch.
di~cnmin:ui\'(' .')en');ltion':l
purt\on of the lllo~t salient features of each ascending palhway.
08
~
Ph,sical Rehabilitalion
.5
., fS . Snsory Signals
~a~b~l~e~5i.~1:F::e:a:tur~eis~o~f~Piaithiw~a~YS~fo~r:ll:r:a:n:s:ml~ss~,~o~n~~o~o~m~iatJ~c~e~~~~~~~~ p'
"'=~ r-----Anterolateral spinothalamic
Dorsal column -medial lemniscal
E
(.
Nondiscriminative e.g., paIn. temperature); broad spectrum Of sensory modalities: crude localization; poor intensity discrimination: poor spatial orientation relative to origin of stimulus Discriminative (e.g., stereognosis, two-point discrimination); precise localization; fine intensity gradations; high degree of spatial orientation relative to origin of stimulus
Small-diameter,
slowly conducting
nociceptors
Skin, joints, tendons: specialized mechanoreceptors
Large, rapidly conducting
Somatosensory Cortex The most complex processing of sensory infonnation occurs in the somalosensory cortex which is divided into three main divisions: 5-1, 5-11, and the posterior parietal cOflex (Fig. S.fiA). The primary somatosensory (5·1) area occupies a lateral strip called the postcentral gyrus (posterior 10 the central sulcus) and includes four distinct areas: Brodmann's areas 3a. 3b. I. and 2. SI neuronS identify the location of stimuli a~ well as discern Ihe size. ~hape. and texture of objects. At the superior aspect of the lateral sulcus i~ the secondary ~omatosensory cortex (5II). \\hich i~ innervaled by neurons from 5-1. 5-11 projecls 10 the in~ular cortex Ihat innervates the lemporal lobe. beJie\ed important in tactile memory. The posterior pari· etallobe i... behind 5-1 and con~ists ofarea~ 5 and 7. Area 5 integrate~ laclile input from mechanorecepwrs of the :)km with propnoceptl\'e input from l1lu~c1e~ and joinrs. Are... 7 imegrale~ stereogllo~lic and visual infomlatlon from vj~ual. t...tlile. and propriol:cptive input.67.6jU~,76 Thc':>e proce... ~jng ilrea'l anal) ze and IIllegrale Ilomatosen... O~ mfonnallon and l:onlribute 10 motor performance by III delemlllllng the Initial pO'litlon requm:d before a l11o"ement o(;cur..,. l2} error detection a~ movement on:ur.... and {3, Idel1llficatlon 01 movemenl QUll·ome ... "Illdl help'" IU .. hape leamll1g. -\nim .... lmodeh ha\e prm ided l:ofhlderable in~lghllnto Iht: tun~tlUI1 of the lOrlllal d~~OCIi.tIIOf1 arc;J.~. Complctl.: relllo\ . . 1 (It alt:a $-1 01 Ihe "'OJ1ldIO~CJl..,ory 'I) ~1l'1ll produce~ dehlll' 111 po..,Jllun ..elht: and the ahilit) 10 dclemune Iht= ~Ill: tnture. dnJ ~hapc 01 obJel"'. Tt:mpcralUrc dod palll pt:fleplll.lIl dre dlll1ln,,,hed hut 1101 J.hulhhed 0" Illg to relJal1U:' on Jl1pUI Irul1I 5-1. relllu\i.tl 01 5 II re ... ull~ In
Skin: mechanoreceptors. thermoreceptors,
From dorsal rocts of spinal d I nerves, synapse at orsa horns, fibers cross and up sp,'nal cord move . through medulla, pons, and midbrain to the ventroposterolateral nucleus of thalamus From dorsal roots of spinal nerves, ascend to medulla, synapse with dorsal column nuclei, cross to contralateral side and ascend to thalamus; then project to sensory cortex.
severe impainnent of the perception of both shape and texture of objects. Animal models have also shown reduced ability to learn new discriminative tasks. which are based on the shape of an object. Insult to the posterior parietal cortex presents profound impainnents in attending to sensory input from the contralateral side of the body." The sensory homunculus (somatoropic map) represents a cross-sectional view through the postcentraJ gyrus and identifies the relarive size of the cortex devoted to specific body parts (Fig. 5.68). Note that certain areas of the body are exaggerated such as the hand. face, and mouth owing 10 grealer innervation density of the skin. The relative liize of body parts represents both the dellsir) of sensory input from [he bod) region as well as the imponance of sensory information from the area as il relates to function. 7S .7c:o For e~ample. the relative 'iize of Ihe foot i~ retlecli\e of ih importance in locomotion; the relati\ e ~ize of Ih~ lnde\ finoer retlects ils o role in fine motor .,kills. In COlllra~l, cortical areas for the trunk and bad. are ~l11all. implying a lo\'.:er receptor den:-.ily and reduced role in sen~or) perceplion related to function. U..,lI1g mo-pollli dl ...cnminJIIOI1 as an c\ample. Bear el al pro\ ide an c\traordinar) Jllu\tration of how our abilJly to perCt:I\C a '11I11Ulus \i.lfIe ... n:m.lrkabl) across the bod)'
fI'J'Olllt Ji\lllllllll/Jfioll rant! \ al le"_\t tH t'1If.\fold file hody..Fmgcrtll" lUll (' fh(' hight!.\f r£'solu. (f{It/. 7 he d{)(\ oj Rrwllt' tile I nUll III!!," and 2 -' film
Th
W 1"(1\,.
ulltlf"f ill' (" _\l ~ dIJt.\ ma~t> a lelft" All t.'~pt.'flen{"ed
Brut/It·
rt:'U
(
la t WI )( 1I1l
till
-
mJt'\ jllllwr across a pagt'
oj IUi'Jt!l! "ttf) lUld 1"((1t! "how bOO !etlt'n I~er mmllte. 11 I/ldl H ro//I'h!, .., us tUllII -WlI/t'one lead/lit;( aloud.
r
Chllplcr 5 Examinalion of Sensory Function
Screening
Postcentral gyrus Central sulcuS_-:>.---- fingertip IS so much b(,tfer II/(II/.}or nample, ,h" e1how for Braille n'ading: (I J There I~ a milch 1t(~,It',. dellsir)' of meChQllOr('(:epfuri 11/ II/(· ~l..i1/ r1 the jingertip thun on othe,. paris of 111(' hodr: (2 J lite jillJ,:emps ar(' enrlclted in reaptor
t.'lU'i I!lm Iw\'c ~mall recep'iI'e ji('hls: (3) Ihere is more hrUlII tlSillt' (alld tltllS more raw computing
('"J demled In l1Ie semon mformalum of ea('1t :l{JlllIre IIlIl/fl/Wler uljillgerrip ,han elsewhere: alld (oJ) O,e,(' may be 5peuallleural 11/c(/UlI1lml.\ r1e\'OIed 10 111~!I·,.e.\Oll/rlOli d,.H.,.itllIlWIIOIU. "~.,> .J4.1~
POll
To perform a sensory screening, several easily tested (i.e., requiring little or no specialized equipment) modalities of sensation are selected. It is important to select modalities from each of the general categories of sensations. For example, the therapist might select pain and light touch (superficial). kinesthesia and vibration (deep), and two-point discrimination or stereognosis (combined). The sensory screening is performed by using the selected modalities to test randomly over somev,,'hat large surface areas. For example, several applications of each stimulus might be distributed over the upper and lower extremities and trunk. The information gathered assists the therapist in clinical decision making. If sensory impairments are identified it may (I) indicate the need for more de.ailed testing, (2) help narrow the origin of symptoms, or (3) provide insight into the cause of functional limitations. As mentioned earlier, screening tests for mental status (arou~al, attention, orientation, cognition, and memory), vision, and hearing acuity should be performed prior to the ~ensory examination.
140
Ph) ..ical Rt.·habilitalion
Preparation for Administering the Sensory Examination Pnl.lr to lnillallllg till,.' t.·\;JmlllalrOIl 01 ,cn...nry llinellan. thc lronmcnt ...hould he identified and pr~parcd. Ill"cded equIpment g.lIhcrlxL and con . . "Jaatllm gl\'cn to pJ1Il"1l1 prl,.'par.llion (I.e .. \\ h;lI II1l0n11allon and in ...trut"llon wIll he prO\ i(kd).
le ... llllg el1\
Testing Environment The . . en ... or) c\Jminallon ...hould be admillbtercd in a qlllet. \.\cll-IIghted Ircatment arc". Depending on the nUIllb~r of bod) area... 10 be te:-.ted. either;} sitling or recumbent po.. ition Illay he u'lcd. If full body tc~tillg i\ indicated. both prone Jnd ",uplne position~ \\ ill be required and use of a treatmcnt table is recommended to allow examination of eal'h ",ide of lhe body.
Equipment To perfonll a ~en~Of) ment and materiab are
e~al11inalion
Figure 5.8 The Tip TIleml® is a thermal instnlm~nt designed
for palient monitoring of !!ross temperature perce~llon of t~e fecI. The instrument is 4 inches (100 mm) long With a .59 tnch (IS mm) diameler. (Courtesy of Tip-Thenn® GmbH. DO ..... ddorf. Germany.)
the following equip-
u~ed:
I. Pam. A large-headed or ,aret) pin or a large paper clip that has one ~cgl11ent belli open (providing one sharp and one dull end). The ~harp end of the instrument should not be sharp enough 10 risk puncturing the skin. If a large-headed or ~afet) pin is u~ed. the sharp end may be further blunted by a light sanding. Commercially a\ailable single·use protected neurological pin~ mi.l) also be used (Fig. 5.7).
2. Tempera/lire. Two standard laboratory tcst tubes with stoppers.
eLls/elL VOl L' 1001
Iham® is
('arly deleu/on idl,ntijicatioll 01 ch£ll1.!!'c.\ ill Iho.",al I,aleptiofl
ji;r
The Til'
(if/
dc\/glll'd fOl" mOl/itrm"g 1'0IrIlC/fl"0IUlfhr tH.'\()ciou'd 11'1111 dwheln rFiJ:. 5.SJ.lt p/"(l,·idt" a IIIc,thud (orl'atients to tnt tellll,crOff/n· .H'lI.\itil>/ly 01 thei, ICc't /"dt'Jlcl/dclI1ly. It 1""\'idt'\ ollly (I ~/{J\.\ I'\flll/alt' 0/ fc'III/'c'I"atttre I'c>j"(·t'pt/Oll. hmn>, 0'. It.\ (0111 c>nic'l/t c 1111\ CII.\I alld pllt/cm,' ahililY to II.H' It lilt·
il/ll'Ol"lcllll I ·helldt'lCf"I-\flf '.\.
11/(11/\ lilllc.\. 1'('tjllll"e,\ 1/0 c'lIn ....: \'.
cial c"hard( '1("/"/ \til·\
If \ \
IIthc·tl
rhe
ItJul {all hf IIwd II.\C of till'
,\I'f-
Ulll!c 1"1111 lind 111('1111.
Om'
and lIIa/..o
C"hl 1.\ fIIl't," lind thl 111'1'0.\111 \lilt {\ \.\llIht'tic IIId/aitll Both II/o/t.,-ial.\ UI"l' ('.\\('111/11111" III I"O(lm ICllllwralllre: h/lw{'n'} lilt· me Iell ('I/d la/..e \ III I/( III tif I,om thc hody (Jlle'flll 1/(/\ (/ 11Il;lIn ("(llId'll firm 11101/ Il't I"l'\ull ('lid
3.
U.,
ii/(, tIIdei/o/d /\ 11('le t/l'e .. I,,, I
II
"·/lIlIl·tll ,II"UI
l·1/11I.
h
II
mall circular di ... h eln be u~ed to measure two-point di,crimltlatioll (Fig. 5.IU). The ...e in.'itrumenh typically allc/\\ ljuan1ifici.llion of two-poinl discriminatIon frolll I to 2:' mm. Electrocardiogram (ECG) l'aliper~~'1 with the tips "andrd to blunt Ihe ends>ill <mel a ~l1lall ruler have also been u,>~d 10 lllca,>ure Iwo-poinl di"criminalion.
CL/lVICAL NOIE: 1lll/ltlin,a St'''''"lIOII i\
cl ("ofl{rail/(!tc1IrW/I Ol"llreUlllIlOlI/()r live (It some plrnicu/ agents hecausc rhe {'11l1 f{JII,1!,l' Ol'llfl'IISJ(" 01 "unl/io!l IS liw/l/(lllt/y (Issue/-
tiled \l'llh IIIl' fll/ril'I/I., \/lh/Ccfn'l' I"l'lwn ot' hcm t!ll'rnter1'l'IUioll/ee!\ (I t',.!'(JI/{,fJl TO/aunn')
The Sensory Examination Figure 5 10 I hh
di ...LrllllHlaUllil l11..,trUIll.:nl pl;]'IIL rUlalllll! II Illl fOunJcd to de~cnbe common ,en..,or~ Impaimlel1t!!. (L/\I( --\L \Orf
IIdlll" \I!"fll. ,tlili/\\
to tlnd .lIlt I Il/f/('nt «(mt,lr a oro~ mal ~PJ or a 0;;'3 ,0) localton 01 the Impairment on a 11mb or body part The dermatome chart should be color coded and lilted In uSing varymg dl?nSily hatch maf~S (t; gher dens 1y' f()f more severe areas ol,mpalrmenl) IndIcate lhe color used for documentatIOn In the box titled Color Gode la dltferent color should be used tOf each S4"'nsat Or'> Separate nolaMn shOuld be made for exammalton ollhe face and Identification of penpheral nerve Involvement Abnormal responses should be bnefly descrobea n lhe comments sectIOn _
Pallent Name: E>..amlner
Sensations
Date:
_
ANTERIOR
_
Upper Extremity Right
Lett
Lower Extremity Right
Left
Trunk Right
Comments
LeU
Pam Temperature Touch Vibrahon Two-Pomt DISC KinestheSia Propnoceptlon StereognosIs Note: Areas shaded indicate sensation not typically tested for corresponding body part. Key to Grading 1. Intact. normal accurate response 2. Decreased: delayed response 3. Exaggerated: Increased sensitIVIty or awareness of stimulus after removed 4. Inaccurate: mappropnate perception of stimulus 5. Absent: no response 6. InconSistent or ambiguous: response inadequate to determine function accurately P = Proximal; D = Distal
Indicate Peripheral Nerve Involvement:
e-
Figure 5,11 Sample Sen')or) E)"anunalion Form.
Color Code POSTERIOR Color
Sensatlon
~;
144
Ph~
.. ical Rehahililarion
Table 5.2 Terminnlogy Describing Common Sensor")' Impairments Abarognosls
Inability to recognize weight
AllestheSla
Sensatton experienced at a site remole from pOint of sllmulatton
Allodynia
Pain produced by a non-noxious stimulus (e.g.. touch)
Analgesia
Complete loss of pain sensitivity
Astereognosis
Inability 10 recognize the form and shape of objects by touch (synonym: tactIle agnosia)
----
Atopognosla
Inability to localize a sensation
Causalgia
Painful, burning sensations. usually along the distribution of a nerve
Dysesthesia
Touch sensation experienced as pain
Hypalgesia
Decreased sensitivity to pain
Hyperalgesia
Increased sensitivity to pain
Hyperesthesia
Increased sensitivity to sensory stimuli
Hypesthesia
Decreased sensitivity to sensory stimuli
Pallanesthesia
Loss or absence of sensibility to vibration
Paresthesia
Abnormal sensation such as numbness. prickling, or tingling, without apparent cause
Thalamic syndrome
Vascular lesion of the thalamus resulting in sensory disturbances and partial or complete paralysis of one side of the body. associated wilh severe, boring-type pain; sensory stimuh may produce an exaggerated, prolonged, or painful response
------
dc'Hllng I' nol required). The ,harp a~d dull end of Ihe • ". , 1•••",dol"I) "pplicd nl'rpcnchcularly to Ihe skin . 1O,lrumt'n t'~., To avoid ,unlmation of impulse:--. Ihe Sllll1UIl should not be :Jpplicd (00 c1o::.e tll each other or ,in 100 rapid a su~ce~sion, To maintain a llllifonn prcs,ure wHh each "ucccsslve application of stimuli. the pin or re~haped paper clip should be held finnl)' and the lingers allo\'-'t:d to "~Iide" down the pin or paper clip once in coni act \\ it.h the skin. This ~ill avoid the chance of gradual1) incrca.. . mg pressure dunng applicalion, The instrument used to le:--! pain perception should be sharp enough 10 dellect the skin. but nol puncture it. Response The patient is a~ked to verbally indicate sharp or duff when a stimulus is fell. All areas of the bod) may be tested,
Temperature Awareness This le~t detemlines the ability to dbtinguish between wann and cool stimuli. Two lest lUbeS with stoppers are required for Ihis examination: one should be filled with wann water and Ihe other with crushed ice, Ideal temperatures for cold are between 41'F (S'C) "nd SO'F (IO'C) and for warmth. between 104'F (40'C) "nd 113'F (4S·C). Caulion should be exercised 10 remain within the.. . e range::., because exceeding the5e temperatures may elicil a pain response and consequently inaccurate Ie,,' results, The side of Ihe test tube should be placed in contact with the ~kjn (as opposed to only the distal end), Thi::. technique provides sufficient surface area COJl1act to detennination the lemperature. The test tubes are randomly placed in contacl with the skin area to be tested, AU skin surfaces should be te~led. Response The palient i::. asked lus application.
10
CLI\'fCAL I\'OT£: Till' ell/llcal 1I.1e!lI/l1l',n o( 'hermal {('s{II/~ 11/(1\' ht' 1)/'(I"'f'lIIa,ll. \(llan-V (>(I/IIf.' oW ,ha{ {he f('sts an' t'\ln'mt'lr dlfficul{ {II dl/plll'tlf(' (11/ a (/llv-to-day htUlS (11\ lilt: {II rapid (h(/I1~t'\ III !t'm/lt'rllluJ'e olin' {hf' rest llIht'.'i CIIt' nfl.ned fjl room (Ii,. \1{h(}lI~h 1/ 1\ ({ Hmph' tt'S{ 10 perforlll. IIf'ffrll/lIl1l1\.? lhllll~('\ (1\'(" rum 1\' nor prauinl1 IIIdt'\\ {/ !//ethud /It lI/ulli{ol'll11.: {ht' {t'}//I'erarur(' of ,he {fst
Thermanalgesla
Inability 10 perceive heat
IlIhn J\ 1I\('cI
Thermanesthesia
Inability 10 perceIve sensations of heal and cold
Touch A\\ aren(".!ts
Thermhyperesthesla
Increased sensItIVIty to temperature
Thermhypeslhesla
Decreased temperature sensibIlity
Thlgmi::lneSlhesla
Loss 01 light touch sensibility
----
repl) hOI or cold after each stimu-
Th .... te'l deh.Tlllltle" p~rct:ptlon 01 tal'llIe touch input. A ldllld-hair hru,h. Pll'l'~ of (olton lball or ::.\\ab), or li::.sue 1::. lI't'd, llw .Ired to Me tl"ll..~d I~ Il~htl\ lOuched or stroked, E\,\llllll~llioll III liner ~rad.ttll\ib l)lllglll (oul.:h nUl be quanlltleLl u",ng llhllloIIL,lml..'IlI' (,~t.' laler "e't.:lion tilit'd Qu,Ulllljll\t" St"lhor~ fe-'lIng ~\nd SJX"I.'IJllzed Te:lting In'trtlllh:,nl" I RnptlllM'
lhl' p.tllt'1ll "~I""'t"L1tu Indll'~HC \\ hl.'ll he or ~ht: recognizes lhat hd' Oct'll itpplh:'l! by rl"''X\lldmg "ye~" or "now,"
.\ ,lllllUlu"
C ha pt,-' ... 5 ElI.a m ina(ion of Se nso ry Function Nufe : A quan tit ative score fo r p:lin perce ption. temperponse::. (yes/no: hot/co ld ). Other o pti o n ~ might inc lu dl" nodding the head, pointing 10 index card s contilinin g printed re~ p o n ~es: or using hand gestures to indi cate recogn iti on of a stimulu s. Pre~surt"
Perception
TIle therapi.; t',,:; fingeJ1ip or a dou ble-ti pped cott on swab is u~ed 10 appl y a finn pressure on the skin sud·acc. This pressure shou ld be fiml enough 10 indent the skin and 10 stimulate the deep recept or::.. nli s test can also be admini stered u~inQ the thumb and fingers 10 sq ueeze the Achill es tendon. 79 Res ponse The patient i~ asked to indi ca te when an applied stimulus is recognized by responding "yes" or "now."
Deep Sensations The deep !-.ensations include kinesthesia, proprioception , and \ ibration . Kinesthesia is th e awa rene ss of movement. Proprioception include~ positi on sense and the awaren ess of join!'> at rc.-:.t. Vi bration refers 10 th e abilit y to perce ive a rapidly o!>cillating or vib rat ory "timuli . Al th ough these sen. . ati on... art' closely related , they are ex amined indi viduall y. K.in('sthe~ia Awarene~s
Thi . , leq e xaJ11jne ~ (J1I '{/rem'55 o!mOl'el1leIlT. The ex tremi ty or join t( . . ) i .. 11100 ed pa ~ ..,ively through a re lalive ly ~ ll1 a ll ran,g l? of motion (ROM). SI11311 increments in ROM are u'>l"d a . . joi nt receptor. . jire at specific po ints th roug ho ut the ran gl:'. Tht.' therapi . , t shou ld identify the ROM bei ng ex am ined (e.g .. initl31. mid -. or terminal range). As d i sc u ~sed, a In:.il run o r dt'1ll 0lbtraUOJl of the proced ure ~ h o uld be perfonncd pri or to ~Ic tual testing. Thi ... will cm.ure Ih al the pall\:"lll .uuJ th ~ theTapl ,> 1 l"nbe verball y the direl'li o ll and la.Jlg!.' oj Il1me n H: Jl! IIltt: rm . , pre;:\ 10w.. l ) di,>cu')"'ed wil h th t' Ih .:rar l ~t (u l). Ju\\ n. In. uut, and ... o tonh) ",h lle the extremIt ) I'" I n OIofJ011 1 hl' P3 t1 t'1lI nld) al'>o re '> pontl b) ...ttnultal1eou . . l) UUpll L l1 111g lht' movement wllh tht' 0ppO... tl c c\.trc-llllt) T IL L... ..,t'L·und i.lpproaLh. hu\\ c ver. I... u\u:tll) IlIlpldllh..al \\-lI lt p w\JtJ1dl hl\\t"1 e~ lrt' 1lljl y jUlIlt:o., uwing Ii) p! lkntl ct' ll1t'd 1110l"e qUlLkl y than th tl! (II ,malier Jtll ll b. Thl" (hailpl\! \. gnp !o. houfJ It'malll l:OI \. . tilllt J. J\d lll lll l llJ .d I tl11 ge rttp .:,!. fJp 0\1: 1" b O Il ~ pn.)t11It1t: ill'n). 10 reduLl' l;lll tl e ~ tlm u l i.l Il O l\
145
Proprioceptive Aware n ess This test ex amin es joint posilion sellse and lite awarcness oljoillls aT res'. T he ex tremit y o r joint(s) is moved through a ROM and he ld in a static positio n. Again. small increment s of range are used. The wo rd s se lected to identify the ROM examined sho uld be identifi ed to the patient during the practi ce trial (e.g ., initi al, mid- , or tenninal range ). As with kinesthe sia, cauti on shou ld be used wi th hand placements to avoid excess ive tactile stimulation. ReSl)OnSe Whil e the ex tremity or joint(s) is he ld in a static pos ition by th e therapi st. the patient is asked to desc ribe the position ve rball y or 10 dup licate the position of the ex tremity or joint(s) with the contralateral extremi ty.
Vibration Perception Thi s te st require s a tuning fork that vibrates at 128 H Z. 19 Th e abilit y to perceive a vibratory stimulus is tested by placin g th e base of a vibrating tuning fork on a bony prominence (such as the sternum , elbow. or ankle). The tun ing fork base (the " handle" of the fork ) is held between the examiner 's thumb and index finger. The tine s are then bri skl y hit against the open palm of the exam iner 's opposite hand to initiate th e vibration. Care mu st be taken not 10 to uch the lines, as thi s wi ll SLOp the vibration. The base of the fork in th en placed over a bony prominence. If vibration sensation is inlact. the patient wi ll percei ve the vibrati on. If there is impainnent. the patient wi ll be unable to di stingui sh between a vibrating and nonvibrating tuning fork . Therefo re, there should be a random application of vibrating and nonvibrating stimuli. Auditory clues can pose a challenge in obtaining accurate test results. TypicaJl y it is easy to hear the sound of the tines making vigorous contact with the examiner's hand to initiate the vibration. If the sound is not heard, it provides an easy indicator to the patient that the next application will be nonvibrating. To minimize !.his effect. the vibration can be initiated for erery stimu lus applicati on: however, when a nonvibrating stimulus is desired. brier contact of the therapist's fingers on the lines wi ll stop the vibration prior to placemenr on the skin. Th is, !.hough , doc!'. nOI solve the problem of !.he auditory cues ge nerated during application of a vibrating stimulus. The. be~t . . o lution i:, use of sound occl usive earphones (the type often worn b) airport ground worke rs). Unforrunately. such earphone:, are seldom avai lable in a clinic setting. R cs p o n s~
The j>alit·nt i.'> as keLl 10 re spo nd by ve rbally ide ntifyin g o r olht'l"wi kln ~urtal't! "'. A tt ~ l e.-teh "pp h Latl o ll 01 a .'1ill1lUl u') Ihe pa ll en! i... gIve n tllne HI rt.!!:>ponci. Rc~ p()nSt'
The pall en! l!:o '-I:-.l.. eJ \(I Identl Jy the loca tltJI1 01 Iht' "'[Imull by plHnu ng [0 the ,m! a or by verhal de::.tTipltun The
Two-point di sc rimination is among the most practical and easil y dupli cat ed tests for cutaneous sensation. Some years ago. a series of c lassic rwo-point di sc riminati on studies were conducted by No lan. 84-86 The purpose of his research was to establish normative data on two-point discrimination for young adults. His samp le consisted of 43 college students ranging in age from 20 to 24 years. Values from Nolan's studi es for the upper and lower ex tremities as well as the face anc! trunk are presented in Appendix A. The res ult s from these slUdies should be used cautiously, inasmuch as they relate 10 a speci lic population. They shouJd not be generali zed for interpreting data from older or younger parienls. Nonnalive data for two-poin t discrimination values have also been documented by Desrosiers et al ,87 Shimokata and Kuzuya.lI~ Hemlann et al. 89 and Ri chards et al. 90 A ~ mentioned earlier. the aesthesiometer (see Fig. 5.9) and the circul ar two-poi nt di sc riminator (see Fig, 5.10) are among the most common devices used fo r measurement. Two re shaped paper clips can also be used: however, thi s reyuires th e assiMance of a seco nd exarniner to measure Ihe di sta nce be twee n the two points using a small ruler. Du ri ng th e te ~;j procedure the two tips of the instrument are app lied (Q the skin ~i mllhan eo u s l y wit h tips spread apart. To iJlcrea~e the vtI!ute lor \tcrcogno,i, \\ hen paraly~i~ prcvcllb gra . . pmg an oh.le-ct.
Figure 5.13 Dbcrimination v.eights are idcn(icallll size. and lex!Urc. The only dislinguishing fealUrc i.!> their \lari4 ation in \\eighl. (Counes)' of Lafayenc Instruments, Lafaycuc. IN 47903.) ~hape.
hand one al a time. place a different weight in each hand simultaneously. or ask Ihe patient to use a fingertip grip 10 pick up each weight.
Response The palient is asked 10 identify the comparative weight of object~ ill a series (i.e .. to compare the relative weight of the objc.::CI with the previoLls one): or when the objects are
placed (or picked up) in both hands simultaneously the patient i~ ..sked 10 compare the weight of the (wo objects. The patient re~ponds by indicating thaI lhe object is "heavier" or ··Iighter.··
ReSI}On~e
The pallen! I'> J,j..,cd 10 idenllf) \erbally the figure ... elra\\ n on Ihe ,l..II1. For pallenI'. \\ ith ,pecch or language impairmenh. the Ilgurt:''> ell1 ~ ... ciC'Lled qminted lOJ from a ~eril:.'~ 01 11I1e dr•.m m.~ ....
Reliability RdiuhtlitJ i, an importanl parameler of an) (eM or meas-
Recognition of Texture Thi, le,t l·\amllle~ the ablltt) In ulfkrentlalC among \1/1;' anJ "h,llk' hUI III ~r.ldu.i1 ... d \\ t:l~hl I' u.,l;'d (J 1g. 5, I _~ I, lilt' thl;'r~\pl...1 1ll.1) ... 111)(/.,1;. 111 PI..II;I;· .I 'I.:fll;·... nl Jllkr\~111 ~\l:lgh", III rhl' "',1l1Ie rUI 1l:11 I!C 1111 hll I
1;011 hllll~
4
ure. HO\\ewr. fe\\ ~)~lemalic report' addre~sing the reliahility of traditional ~ensor) tt"~h appear III the luerature. Thl' i... li~cl) due 10 the inabilil) to accurate I) lj1l31ltlfy I~SI re ... ulh. In an illlpon,m( earl) reliJ.billt) ~(uoy hy Kent')l Ihe upper IlOlth of 50 adult patienb \\ ith hemiplegia \\ere le~ll;'d lor \en. :.I'lpel.'ll)f Iht" h~,.,b. Including {I) lI'\e uf l'onSISh:1ll gUlddlllt", lor eompkllllg thc le~I:">. (21 aJlllll1l~tration uf the- le- to a 90 angle 1m te~ting: \\ hen folded it proIt.'"(.:h tht' monofilamclll \\ ht:n not in u...e.
\(111
hI:) Ar.: . . thl:\IOmCICr.
TIl .... \et
149
conl"in..
17 111l1lloliILllm:nh mounted un p!l:\lgb.. . , handle .... (Coline ... )" 01 SOlllcdlL Sale ... AB. lIurh) . 'i\\ edell,)
Rydel-Seiffer 64/128 Hz Graduated Tuning Fork S Neurologicals, Kirkland, \VA) Thl') qualitallve tunll1g for'" COnlatn~ ~mall scaled weight~ on the dl'\tal end(, of the two prong~ converting it from J 28 Jo 6-1 H7 (Fig. 5.20). The J\YO ,riangle, move closer Joge,her and their inler"ection moves upward as the intensity of \ ibrution decrea... c~. The intensity where the patient no longer perceives the vibnuion is recorded as the number adjacent to the intersection of the triangles. This instrumenl allo\\ ~ more sensitive and ~pecific testing for detect· ing "em,or} changes as compared to qualitative lUning fork~ and ha.. demonstrated high inter- 4ind intratester reliabilll).lo7
Rolltemp (Somedic Sales AB, Horby, Sweden) Contralalef"al Comparison
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This instrument is used as a screening tool for determin· ing changes in perception of thermal sensation (Fig. 5.1 J). The roller~ are housed in a ~lOrage unit to maintain temperature. The individual rollers are placed in contact with the ~kin to provide a gros~ estimate of temperature perception.
r.k,•• t
o..... a1 looIdl.1
Figure 511 Compulc:r-gt'l1t:rLlled dala from thermal h~"lll1g lhoJl pre c.-ni') d (.omp.tfI"Un kr"t:l'n rhe IV.O ",de;,> 01 Ihe bod\ 'Jh: lilc d..tIJ lor lhe n~ht IUOI pn:..enh (on:..I')lcnrl) hll:!her . thn: !Lold \calt: on the It'll horot'r arl" 12 ( - KtJfd· and 50°(' = 111 r (ltlUrle,,) 01 Mc:(hl LId Dl.Irh•.ull, 1'« 27707 I
Figure 5.19 Intlllddllal monofilament (Counesy of North Coa-.t Medlc.t!. Inc, Morgan I-lill. CA 95037.)
Physical RehabiJitation
150
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Figure 5.21 fhl: Rolltc:mp PIO\jJt'~ i.Il.juid, \lrC:Cl1ln!! ltll)1 lilT tht'f111i.ll "c:n .... tllUll, file: rollc:r~ an: rnOUll[C:u tin h,uldlt::, anJ sltlrt"d upright tnlhc 1\\0 sqUMe 1l1'>CrllUll POUlh un thc: "'lora~l' unn (jIlt; folk, I... 1ll.lIlIlelt:l:llon ot d trealment model i~ ba~ed on a complele data "et of II1hH111ation trom all examination" logelher with tht e"lahll"hed prognmi.., and (!lagnm,i,. Thc tre;'llrnent approach depltted U1 Fi!!ure 5.11 1\ bi.l~ed ldrgel) on the Si'Il\Uf) lnltgrdllon Model de\elupt:d by AYCf~.' Illl-ll':111e b,hll prCI11I'>t" 01 fhh <J.pproadl 1\ Ihal ~pel.:lfil lre;,ltmenl It:dulIque, l'i1l1 t"nhdm:e 'ensof) 1l11c:gfdlion (eNS pn>l'e~~ mg) "Jlh d fc:\ultal1llhange in mol or pertormance. l..,lng the Sen\ory Inh;t!r~lllon Approo.lch, dala OblJlllCd trom Ihe eXdminatlon ot "el1\ol') flllll'tlon
infofl11~ development of .1 POC 10 enhance opportunities for Coll1rolJt·t/ st.'n~ory Intake: \\ uhin a framc\\ ork of meaningful funcllonal sltlb (~ee Chapler 13), DUfing IrealtllCm, the patlenl i~ providt":d guided practice in planning and organizing mOIOf behavior~ uSing both intrill'.ic feed bad.. (from rhe movement itself) and 011'<Jnt'ntetl feedbad. (cue~ pL.lnned by Ihe therapist). Thl!) approach 1\ de~lgned 10 tmprO\e lhe ability of the eNS to prou.. ,~ dnd IIllt.'gnuc Information dod promole motor le;,trnlng. The reader h referred 10 Ihe '" ork of A)cn,1 llll', II..' and Bundy lind f\lurray' for a Jeullled presenlalJllll of both lht" theol)' and practil'e of the Sen,ory IJ1Iegratlon Mudel
152
Phylliical RehabiJitation
Box 5.5 Screening Tests for Cranial
Examlnahon
NCn'CS 9 ,62
CraniaJ nerve I: E'\amine olfaclory acuity using nonno:\ious odors such a.... lemon oil. coffee. cloves or lobacco, Cranial nerve II: Examine visual acuity u,ing a Snellen chan; both central and peripheral viSion are tested. Cranial nerves III, IV. and VI: Detemline equality and size of pupils; reaction to light presence of strabismu.ell'OI)' l'onlrol III upp!l f'cufl1h)g) RO:pllrt (no" JNPT!:!6( II:J1. 10(J2 .l GhCI. C. and Kral.auer. J TIlt" org.IOllall(ln "rmo't"l11cnl In Kandel. ER. Sdman/. JII .•md JC""l·11. TM PnnC1plc~ 01 Neural Sueno.'. cd. 4. McGr:lw·Hrll. Nc\l, Yurko :2000. p 65J. 4 A}~'r" A1 SCtNl1) 11Itc!!-r:mon and Pra.\i" 1;"\t" (SIPT Manual). \\'l'"lem P"ychulngical Scn. ICC'. LA\'> An~dc\. 1989 . 5 Bund}. AC Jnd ""lufT3~. EA: Sen\orJ Inlcgr:lllon: A Jean Ayre" ,heo" re\l~tlcd In Bund}. AC lane. S1. and 1Urrd}. FA Scn"~1) Integl'3tl(\n~ Throl) and Pra(llC'c. ed 2 FA Da... I.... PhiladelphIa. 1001. p 3. tl. Iyer. MS. :Itld P~lIrdtl. LW: EV:lluatioll of \cn":llion and Ireatment of ~en"or} dy"fulICIIOll In Pcdrelll. LW. and Early. MB (cd,,): On:upauon,11 Therapy: Prattlee SI.II'" for Phy"ical D},>function. cd 5. CV Mosby. 51 LaUl'. 1001. P-122. 7. Amencan Ph} "ltal Thcmp) As"oualJon: GUide to ph}~leallhera pl"t pmctiee. Ph}" Ther 81'1. 2001 8. All1l1lofT. MJ. et al: Clrl1leal Neurology. ed 3. Appleton & Lallt=e. St:unford. CT. 1996. 9. Gllmllll. S. and Newman. SW: Manter and Galz\ E.'"entials of Cllme:ll NeuroanalOIl1} and Ncuroph)"lOlogy. cd 10. FA Da"i". PhiladelphIa. 2003. 10. Swan. M. el al Effecl'i of agmg on \"Ibrailon delecllon thrc~holds al \:trIOU' bod} region'. Br>.lC Gcnalr 3( I J: I. 2003. 11 Woollacott. f\lH. ShUlllWa}-Cook. A. and Naalion. J Gcronlol A BioI Sci Med Sci 6OA{I}:I09. 2005. 15 McClenaghan. SA. et al: Special char:Kteri"tic, of aginl,! po!>lUral control. Gall Po"lure 4: 112. 1996. 16. he....on. BD. et al: Balan,'e perfomlance. force producllon. and 3ClJ\lly le\el" III nOlllnsltlutlonaliled men 60 10 90 yea.... 01 age. Ph>, Thcr 70(6):348. 1990. 17. Slone". MJ. and KOlma. A: Balance and age in thc "Ighlcd and blind Anh Ph}, ~"ed RchabiI6~Hll:85. 1987 IS \'alenI11n. SA. el al: Ch.lnge in \Cn'>Ol) tunolollmg predICts l'hange m cognill\'e funcIIOl\inf!: Re~ults trom a 6-}e.... loJlo\\-up mIlle \1:laethllr\ rt} rn the humlln foohole J Geronlol A BioI Sci Mcd Sci 5H/81:680. 2003. 20 Hughe~. MA. et aI' Tht' reiatlOlhhlp of po"lural "way 10 M'1ll>Onmo. tor lundion. lun.. ,md "mokrng. and ('ak-ulalron of 'I~r.:urale lentr!e \ al. ue . I)labet M...d 8:157, IWt) ~l de lI;t'dint! J"J el,.tJ Sen'>Ol) thre"hold.. 111 older adulh. Ro:prlldu~ibtlll} .llld rdert'na \.tlue:.. Mu,,--Ie l\ene 17:454. Il}lj~ ~-I GC:>I.helder. (jA d at TIl of Neurolllu!>culoskeletal Treatment and Management: A GUide for Therapists. Churchill Livmgstone. New York. 2QO..:.1 75. Beiir. M F, Connor~. BW, and Paradiso. MA: Neuroscience: Explonng the Br-Lun. ed 2. Llppmcon Williams & Wilkins. Pltiladelphia.100 1. 76. Gardner. EP. and Kandt:! . ER: Touch. In Kandel, ER . et al (cds): Pnm': lpll!)' of NeuraJ Science. cd 4 . McGraw- Hill . New York, 2000, p 451
77. Jano~. Sc. ..nd BOI')sonnault. WG : Upper quarter !>creening examin"lion. In B OI~:.onn ault . WG (ed ): Primary Care for the Phy.!> ical Therapl "!: Elment 01 cutancou), \cn!.ory (untlloll. Clln Malldge Phy)' Ther 4::!6. 11}84. ~O \\erm'(' JL. and Om!!r GE: E\"aluntlllg LUt.lIleou ... pre"i> ure ...en!'. :!tlOn 01 the halEd. Am J On;up Ther :!~ :34 7. 1970, ~ I Cenh:!f" lUI Dj~ell')e Control and Pre\en UOIl ICD ): G Ulde hllO;:-~ tor Hand H)glc::m: III Health -Cart:' ScEllllg\: Re-{;OmOlcndatlon \ or the HCdhh~iife Inkctlol1 Control PractlCc~ AU\I",uf\ Committee and thl;' HlrPAC/SIlEA/APIC/lDSA Hand H ygien~ ra~" Fur..:!!. MM\\m,g abilit ies and (;apati llc~: Sematl(lli. In lrumbly. CA J.lltl Rddmm\"i. M\, (ed ... ): Occupallon,,1 Therapy tor
155
Phy sical Dy... fun ctlon. ed 5. Lippincott Wilham' & Wilklll.... Philadelphia , 2002. p 159. 8:l GUlmnn . SA . and Schonfe ld. AS: Screen ing Adult Neuro logic Populations:: A Step-Sy·StCP In'-,(fuction Manual. AOfA Pre\'). Belhet-stToke eentTal pain (CPSP) studied by statistical quantitative sensory testing within individuals. Pain 109(3):357.2004. 98. Hagander. LG , et al : Quantitative sensory testing : Effect of Sill' and pressure on vibration thresholds. Clin Neurophysiol 111 (6):1066.2000. 99. Haye!.. KC. et al: Cl inical and electrophYl.>iologic correlates of quantitative sensory test ing in patients with incomplete spinal cord injury. Arch Phys Med Rehabil 83( II ): 1612, 2002. 100. Lund~lrom. R: Neurological diagno')is--aspects of qU~lntitative sensory testing methodology in relation to hand-ann vibration syndrome. lnl Arch Oceup Env iron Health 75( 1-2):68.2002. 101. Polianskis. R. Graven-Nielsen. T. and Arendt-Nieben. L: Computer-controlled plleumatic pressure algometry-a new technique for quantitati ve sensory testing. Eur J Pain 5(3):267, 20(H . 102. Rommel. O. et al: Quantitative sensory testing. neurophY ... lologlcal and psychologica l examimuion III patJentl.> wi th comple .. regional pain l.>yndrome Hnd hemi\cnsol) dt'ficil~ . Pain 93(3);]79. ~OOI. 103. Rosenberg. D. Conolle)". J. and Dellon. AL: Thenar eOllllenl't' quantltali \'c semor) te~tlllg in lhe diagno\ls of proximal mcdian nerve compres\ion. J Hand 'Iller 14 ~~) : 258 . 2001. I04. Sa mue l • .Ill.' l"e \\ hile. OUlllNI
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".til J;f!:Jlh .tllel.:l .1 patlcnt· ... lUnl.:l101l h~ Gw .. ang tmp.llnndlh ,u~h .1' p.tlli. llllhmm.ltltUl. "'\l~lllng_ ,trut,;lurJll.t\':hlmlll~ 1l.",tflLh:J JOint nlO\ .:ment. JOint lll .. 13hIlH~. ..tOo lllu ..dc \\cJLnt' ..... l::.\"lI1\ph~ .. 01 dIJ!!no,I" tholl re ..ull 10 Jlret.1 11Ilj'JlrmCIlt of thL' nlU ..clJl()... ~~lel.d ...)-.(elll inLlude lradurl'. rheumawl\J Jrthnll'). o... teo..tnhntl\, J\JlIlt di ... lexiJ\Ion, lendlllill'. hur'\ltl'\. lllu\Lk ...train:ruplurt". and IlgJ-
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"prJlnlruplun.. patholuglLJI I.:OnJIIIOI1... IhJl 101110.111) alleu other bt.xi) ...) "'h.'I1l-. ... ulh ;h the neurologll.tl. cardu.)\ :t...luhtr. or pu!nhln.U) ...) '\le'llh caJl n..... ult III -.econdJr) or II1c.1Jr('u Impalnnl:lll nll.he mU'>l'ulo"'htlctal \) ... tem. Thl,", ollen OCCllr... \\tk:n pJllem,· .ILlI\ 1I1t"'\ .ue rc ... tnul'd b) the l·ondillonpl'rhJp.. ..I'" a rc ... ult ot confinement for a penod 01 time to a
rn~m
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t- easily forgOllen. but the inter\ ie\\ ~hotlld flo\\' an active com'er... ation. not a dictation rof), The p"lllelll·~ ag~ and gender \hould be noted: "tlme condltlOI1'- .tre more COlllnlon in p;Jnicuhtr a,gc group~ ;lIld ~ender". Olten. i.ktJlled informatIon about a p;Jtiem .... ()(UlpJtIOIl. rCL'fl'i.Hlonal acri\ illC'5, and ...()('ial It\ Illg "'1!U.tl!on ,Ire rl'Lllllrl.'d ro under,>t.lnd the GllI,e (It the lI11palnllel1h. IUIlI.lll)ll.11 1ll1'lltatlon~ . .Ind 10 dc\ dl.)p ;J rt'I~\ ani pl.m 01 l\lre thai hk.l"l.'''' 1.)11 lhe patle-Ill's ,go..d" 0JX'n~cndeJ ob]cl'ti\t' quc'>t1nn" Ih..11 dL) not pro1111.)lI.· hl..l"C'J an,,\cr... ,hOlild he ll"l'J. Ft)!" l":lmple. Illste-ad ~Il .'''~IIl~ "1" ~ ilur nghl I..."t·e palnlul'l" the.: Ihcn.lpl:>t :-.hould .I'''. \\ hl~r~.' .Ire )0111 '~lHphmh 11.)l.atclP·' rhe (herapl",t ,>hnlllLl t: ..m:lull\. g'UI lIe II' 1t: Illh.'r\ le\\ to "eel' II fOl'm~ed un pertl.lelll 1Il10rlllilloil ..tillI l'~llll' Imit· In .llnnel) manner. All ' \
t11,.lhllll~
\
. I 1 h lilt: p.lticnt 111,1) ha\c c'\:pcricnccd: 1111111 111l·dll ..d c0l1l11 l ( 1 , . 1h ton ;Jllll p.ll!cnl "age. OCCUpe4uem:e ,... ~ugge ... led it ... a \Nay 01 organIllng Ihe Inter\ lev. SlIllIlar ml0rl11allOn on general pdllell\
intcn ie\\ lng. thaI II1clude~ :-.hght \arialions in fonnal. can be found in 1~X.1'l b) Talley and O'ConnoL/) Hertling and Ke,>slcr, I and Pari,:>.
Opening Question ThL' IlllcrVlew ... hould hegin \\ ilh ~I general que,>{ion such as ··Whal bring ... you 10 ph} ... iu.lI therapy today'?" or ··What ....I..Tllh to be the probl~m'!" II the pati~nt i~ hospitalil.ed the que~tlon mal llct"d 10 he rephra ...ed 10 avoid having the patIent relt'lt the medK'al hi"'l)r} (0 t'\t"ry health care
Chapler 6 Musculo.!i>kelelal Examination
i63
pril\ Hk'f "I ... el' from your medical chart thai you fraclUred lour hlp .ll1tl undt'f\lent a ... urgical repaIr yeo;;lerday. b that ~"l.Il h;lppencd'j"' Thl' r~ltl~nl ...hould be given the opportunlt~ III pre"'l'llt the ... lOf) Aller the patiellt ha~ concluded his tlr her .. tJIl'menl. It .\ .lrrropn~l1e 10 5oa) ...That .... good. '0\\ I h.IH' In H.lea of the prohlcm. I h~l\e ,,;ome other lJul· . . wln... I need 10 a.." to help mC' undcr..tand your probkill heller:' Dl'"pendl11g on the infonn3tion provided by the p.I1ICnl. "'ollle 01 Ihe follcl\llllg que~lions may be a~kcd.
On,el of Symptoms
L2
"Ho\\ did lhi ... pain (.. \\elling. limitation. problem. and so
E\o.iI"""'' L3
10flhl hcglll'!" The therapi . . t mll:-.t "now if the onset was .. ud;01 g'ouP In 9'OUII' Th'l dCh."9 Pteumg
G/OUP I
G_8
Group 9
Ho.
T'''9''"9 IIChll'''iI
F1",,,"11 ShooTI"9
B"rn."'iI Suld''''I
G~lng
C"mplrog C'u.... ,"9
.
....
GrOUP /0
RMQ.ng $phulng
Dull
re'>der ,~
Sf'''''''9
St.ngt"'9
Hurtlr'>g Ach,"'9 Huvv
G,OU/I Il StClo.en.ng SuI'OUI I"'"
Group 13
GfOU(114
GIOtJ(J /5
fur!ul Frlght!ul Ter"I'I'''9
P..... ,s,h.ng Gruell.ng
W,elched 8hml,"9
s..."''''9
c.... VtCOOU, K.lI,"9
Groo..c /6
Croup"
""fIOY""iI TtO<JO,nome M'''''flb'e Ina'nSf
Splud,"9 RMl'.llng Penel
\kohol'
(H~ ..lIl'"1ll 'Illil 1Il~ h.I' l"C'cll
Rcu·.l1lOtl.ll
"uh \t I- r l'nl "'llIe tll-'n 11\. '(C.lta ,pll1.l1 d",,~ t1c~C'~rJ' 111'0 • tllde,ll"J Itm h.J\ 1'''11\. .tnt! 1I1f."le.t...rt! upprr .tIll..! I'I\\C( 1'\III'mll\ lIlu'tUI(l,lcktal tI' ..nrdcr'.·· .. l of .llll,hlil .tIIt..! (l'l-rc.!lIonJI dru~, l.ln IC,ld lO n ... ~ t.tktng heh.!\ IN' ft"'lIllJn~ III lOl rl·"-.co In" uklKe of '"June.... ur t!lllil-ult\ In ..,Jlt'h pcrtllmllll,l! lundlOn..t1 JlII\lIleo:, and hOIll'" e~all rn.l~rJJ1l" Iltcrap"t ... m.l) \\""h to advlt:te J pJllcllI Itl rl"Juu~ lhl." U'tC' ot thc~ ,ut"t.lntc, .md rcfer the r,ltlt:nt 10 .Ippropnale ..rX:lal ...en 'l:~' or \cll·hclp orgalllza·
,lltl " "
J ..... ,'Il.I.lfcd
Ilor" h\r loul1'c:ltng.
\nticipated Goals, Expecled Outcomes, and lime hame of Recmery "\\h.eletal condilions. provide the appropn:lIC bac"-ground on \\ hich 10 base and develop patienl Inten ic\\ que'tion~.
Mental Status During (he illlen ic\\. Ihe paticnt's oriental ion 10 person, place. and time a'l well a~ general arousal stare and cogniti\c and communication abilities should be noted. If deficit:-. in the ..c areas are present, the examination may need to be modified to gain accurate infonnation. The use of simple words. concise in':>lfUctions. and task dcmonstra· tions may be helpful. Distractions in the environment should be kept to a minimum. Communication difticullies may be overcome through the use of foreign language interpreter~. geslures. drawings. and language boards. Changes in medication,,;. upright posirionmg. and access to natural light \ ia .... lIldows and !-.kylights may improve patient arou ...al and orielllation to time. Depending on lhe t) pc of deliclI. rhe pide In Ihe ca~e of ho!-.pilt provides the muscle force needed 10 perfoml pas\j\e ROM, rather than the patient. passive ROM (unlike active ROM) does not depend on the patient's muscle ,Irenglh and coordination. Pain during passive ROM is often due 10 moving, ~trelclllng. or pmching of noncontraclile struclures. Pain occurTIng at the end of passive ROM may be due to \(retching contractile struclures. a~ \\ell as noncontractile structures. Pain during passive ROM is nol due to the acti\'e shortening (contracling) of muscle and the resulting pull on tendon and bone attachments. By comparing which mOllon ... (active \~ passi\e) cause pam. and nOling the localion of the pain. the Iherapi~t can begin 10 detennine which injured tissues are involved. For example. on examination a patient is found to have limited and painful active knee flexion. This pain and limItation may be due to a le,>ion in the hamstring muscles (includmg lendom. and bone anachmems,. the quadriceps mu",c1es (includll1g patella lendon and bone allachmems). IlblOfemoral and patellofemoral Joint ~urfaces, meniscus, JOlllt cap~ule, collateral and cruciate ligament~, or various antenor and po\tt:rior bursa. If the patient had similar pain and Iilllllation during pa'>'>I\'C ROM, the quadriceps muscle .... tlhlofemoral and palellofemoral Joint ~urface~. men iscu"', JOIOI capsule. collateral and cruciate Iigamems. or variou ... antenor bur...a mil} he mvol\ed. The ham"'lring musdes \\vuld not be Implicated as these ~truclure... are put on ... Iack .md rellc\cd of tension dUflng passive knee flexion. Careful LOlhldt:ratlon of patient hi ...lOry. ob\ervation and palpatlvn finding .... and Ihe results of additional le~l.s '.:ouch a... end-kel, delermmalJOll. cap... uldf ver... u~ noncap...ular JOlllt IImltallOn pallcms. il\IVC knee flexion ROM were now nonnal and pam Iree a:,> cOl1lpareulO painlul during aUlve
A
c
,,.,.""""-;r ..... - -r" .... .... .. .
l'ttl~~
:., i,
j",., ••. ~, .,
Figure 6.10 A variety of metal and pla"'lic universal goniome. lers in dIfferent sizes and shapes. All universal goniomclers have a central "body" with a prolractor and fulcrum 10 center over the palienl's joint. as well as two "arms" to align with the patient's body pans. (From orkm. Cc. and While. DJ,n. p1! wilh permission.)
flexion. a lesion in the hamslring muscles would be likely. The perfomlance of resisted isometric muscle contracljons would be used 10 confinn the presence of a lesion in the hamstring muscles. In the clinical setting, pas~ive ROM is usually measured with universal goniometers (Fig. 6.10) or less frequently with inclinometers (Fig. 6.11), tape measures, and flexible rulers. Visual estimates should not be used because they are less accurate than measuremems taken with uni· versal goniometersy.58 Both the beginning and the end of the mOl ion are measured and recorded so as to clearly indi-
cate the ROM (Fig. 6.12A and B) Using the most common notation system. Ihe 0 to 1800 system. all motions excepl rotation begin in anatomical
___________
C
o Figure 6.11 Se\oL'nl I • • IIlI.. mUlllcler" or ,gra\ Ily-dl:pl.:lldrlli ~onll1ll1eh::r". Each u... · · I the r.am· pie. I! the t,tbo\.\ JOIn! ha... 5 of hypermobil it) in ~xlen"'lon Jlld I-W 01 Oe\loll. it would he rt:l'ordcd a... 5--0-----I-lO°. H~penllOblltl) ur~mell1 ~l'" C'(lrnpar~d 10 normal value..., \1ea,>uremenl re'>ult .. are IIlcorpor..l1ed 11110 nJ.rrati\~ rClAm,> or rculrdcd on '>pt:I.:lallzc:d lorlll'l (Fig. 6,]31. Text:. b~ '\or~ll) i.ll1d \\hitc.~·' (,br~ ...on.'\(' and Rce~e and Balldyl>lJ pro\ ltJe dCI lhal no lurther motion "houlu on Uf. u,u"lll) bectll,e of p..Ull 1 he .lhlll!) to detcrmllll' Ihe 1) pc ll! t'mt-fcl'l I" Importilllt III helping th~ thcrapt ... t ideIllJ!) Ihe limiting \Inlt..:IUle'i l.: a fo(u ...cd .tIld dtecti\1: Ir",allllt"nl De\eloping
172
Pin ...ical Rch.thilit3lion
R:mgc 01 Mollon
Lo\\cr E\lremity
Dale of Birth P:llicnl", N:UllC
RighI
Ldl
Dale E'3I1lincr.... Inllial...
Hip Flexion
E:\lcn"ion Abdul,tion
r\'1cdial R0I3tioll Lateral ROlation Knee
Flexion
Anl"e DOf.. inexion
Plantarl1exioll Inversion
Tarsal
Eversion
Tarsal
Inversion
Subtalar
Eversiol1~Subtalar
1m ersion-Midtarsal Eversion-Midtar~al
Great Toe MTP Flexion
tvlTP Extension MTP Abdu(..'lion
IP Flexion
Toe MTP Fle\ion MTP E \len"IOIl MTP Abduci ion PIP Flexion DIP Fle\ion
DIP E\.lclhlon COl1lll1elll~:
Figure 6.13 R.lll!!\,' of motion recun.Jtng lorm tor Whlll.:, OJ. .' '" \\ Ith !)Cnllh'>IOIlI
Ih~
lu\\\,(
e\.ll~lllll). (From Nor~lIl. Cc.
and
Chapter 6 Musculoskeletal Examination
173
Evidence Summary Box 6.1 Outcome Studies on Reliability of Using Universal Goniometer to Measure Elbow Range of Motion Reference
Subjeds
I)esign/lntervention/Duration Results
Hellebrandt et al,61 1949
77 patients
Repeated measures design AROM 1 highly experienced PT tester 8 average experienced PT testers 2 trials by same tester, time between trials not defined
Highly experienced lesler had mean difference between trials of 1.00 for flexion and 0.1 0 for extension. Sig difference between trials for flexion
High intratesler reliability. Sig difference not c1inically important. No data on elbow motions for average-experienced lesters
Boone et 81,62 1978
12 heallhy males Repealed measures design 26-54 years AROM Standardized melhod 4 PT testers with 5-20 years of experience 3 trials by each tester in one session 1 weekly session for 4 weeks (4 sessions lolal)
No sig difference between 3 trials by each tester in one session so session means used in intra- and intertester calculations. Sig difference between testers Intratester r = 0.94 SO = 0.2' Intertester r ~ 0.88 SO ~ 2.6'
High intra- and intertester reliability. Intratester reliability higher than intertester reliabilty
Rothstein et al,47 1983
12 palients had elbow measured
Repeated measures design, blinded PROM; method not standardized. 12 PT testers with 1-4 years experience 3 types of universal goniometer: large metal, large plastic, small plastic 2 trials per goniometer per tester 2 testers evaluated each patient.
Single trial: Intratester reliability r = .95 - .99 ICC = .86. - .99 Intertester reliability r ~ .89 - .97 ICC ~ .85 - .95 Mean 012 trials: Intertester reliability r = .94 - .97 ICC = .89 - .96
High inlra· and intertester reliability. Inlratesler reliability slightly higher than intertester reliability. Minimal improvement in inlertester reliability by using mean of 2 trials versus score from single lrial (differences in ICC no. 0.12)
Grohmann,6J 1983
1 healthy aduit
Repeated measures design, blinded No sig difference between Elbow held in 2 fixed positions: 1 obtuse methods and 1 acule angle. 40 PT student testers used over-the-joint and latera! methods to measure each position 1 trial daily for 4 days
No difference in using over-the-joint method or lateral method of measuring elbow position
4 healthy adults,
Repeated measures design, blinded. AROM 4 testers Each tester performed 5 trials on each subject in one day.
Intratester reliability r = 81
High inlralester reliability
Repeated measures design, blinded 46 PT student testers measured with 2 instruments: plastic and steel goniometers 3 conditions: ALIGN = elbow in fixed posilion wilh landmarks noled, ASSIGN = elbow in fixed position with no landmarks, PROM = full range of passive flexion
ALIGN plastic SO = 1.8' - 2.1' ALIGN steel SO = 2.0' - 2.6' ASSIGN plaslic SO = 2.5' - 3.0" ASSIGN sleel SO ~ 2.5 - 3.4° PROM plastic SO = 3.4' - 3.8" PROM sleel SO = 3.9' - 4.2'
Variability of scores increased as standardi· zation of measurements decreased
Walker et al,"4 1984
Fish and Wlngate,64 1985
60 years
1 healthy adult
Comments
(COI1fmuedj
174
Ph\'sical Rehabilitation
Evidence Summary Box 6.1 Outcome Studies on Reliability of Using Universal Goniometer to Measure Elbow Range of Motion (conl;nucd) Reference
. Subjects
0 eSlgn . II nlen'enbon • ID ura I'Ion RC~ ult.
Greene and Wolf,66 1989
20 healthy adults 110 males. 10 females) 18-55 yea,,;
Repeated measures design AROM 1PT lesler 2 Instruments: universal goniometer and pendulum gOniometer 3 trials per instrument In a sessIon 3 sessions within 2 weeks
Universal goniometer within· seSSlOns: Flexion: ICC = .94; SD = 1.2"; 95'!oCI = 30'; ExtenSion: ICC = .95; SD = 1.0'; 95·.CI = 1.9'; Bolh Inslruments had sig difference between sessions. Low correlation Ir ~ .11 - .21) and slg dIfference between instruments within-seSSions
High inlralesler reliability with universal goniometer in one session. 95% 01 time reliability Wllhln 2_3" It laken by same tester in one sessIon. Differenllnslrumenls should nol be used Inter· changeably.
Goodwin el al,65 1992
23 heallhy lemales. 18-31 years
Repeated measures design. AROM 3 expenenced lesters. 3 instruments: universal goniometer fluid goniometer, eleclrogoniomeler. Landmarks noled on skin. 3 tnals per Instrument by each tester In a session. 2 sessions 4 weeks apart..
Universal goniometer intratester reliability between sessions:r = .61 - .92 ICC = .56 - .91. Difference in means between sessions =- 0.9°; Average difference In means between testers = 5.1°; Sig differences and mteractions between goniometers, testers, and sessions
Moderale 10 high inlratester reliability between 2 sessions 4 weeks apart, depending on tester. Differences between sessions smaller than differences between testers. Different instruments should nol be used interchangeably.
Repeated measures design. AROM 51esters of varying experience. 2 Instruments: uOIversal goniometer and eleclrogoniometer. 2 trials per Instrument by each tester On same day
Universal goniometer: Intratester reliability for lIexion: ICC ~ .55 - .98, mean difference between trials = 3.2';
Moderale to high intralesler reliability. Moderate intertester reliability. 95'. of time reliability wilJ1ln 6.7' d taken by same lesler. and 9' It taken by d,fferenlleste,,;.
I
Armstrong et al,67 1998
38 patients With history of surgery lor upper extremity injury. 19 males, 19 females 14-72 yea,,;
Commenls
95°oCI = 5.9° ExtenSion: ICC
= .45 - .98. mean difference = 3.5; 95°oCI =- 6.60 lntertester reliability for flexion: ICC = .58 - .62. mean difference = 6.4"; 95'}oCI =- 9.2"; ExlenSlon: ICC = .58 - .87, mean difference = 7.0°; 95%CI = 8.9'
=
ARO'\1 aLll\e r.mge of mOIIOO; CI lonfidence mlen"l ICC I .. = mtrill iJ\\ correl.Ulon CoetfiCI~Ol. PROM therapl,>t: r Pe.tr\Orl', corrdatlon t,;oefllneOl; 'Ig \Igmfkam
lhi~ abihty ta~e~ practice and \Cnslli\-II). Pa\\ive ROM. parlicularly lov.ard the end of Ihe motion. mu\t be pertormed ~lov.l) and carefull). Secure '>labiltl"JIIOn of Ihe bone proXimal lO Ihe JOIOi bcJllg le~lcd j\ uilical in pre\cOlmg multiple jOlnl\ ,md "'lructure~ from mO\-lllg and Jnlerlenng "'Jlh delenlllll.. and C)nax'l> mlliall) dl"'\lTlbed l:haraueri'\tH.: path:m oj rl"~lrl(,:(cd jomt ROM due to dIHu...c. IOlra-dftu:ular iOflJ.l1unallon 111\01\ 109 the enllrt: Jomt l·ap"ulc. nle\e Pdttc:m... ot re lrl!.. led mOllon, \\hll..'h usually Il1\ol\e multiple
pil\'I\e nmge- of motion; PT = ph)sical
mOliom ill J -JOint . are ca'11ed capsular patterns. The resrnc.
tlon\ do not 1000he the 10.\... of a fi'(ed number of degrees, bUI rmher Ihe lo~\ of . '. _ . , a proPUnJon ot one motion rdatlve ro i1110lher Cap\ular pat,e . . . _ . m ... \ ar) trom joint to join!. Table 6.3 pieselll~ ('Olllmon ("I I . < P\U ar pallem" a~ described by Cyn3'\ and Cyriu\'tl 'lilt K'I Ix ' < ( a len )ffi."' Although therapists have been u'ling l.' of the iIJopsoa.. . mu:-.de \\ III rc:-.ult in the noncapsular p:H{~rn ot Ilin lied pasl,l\e hip e\len~ion; the pa~si\e range
t 76
Physical Rehabilitation
Table 6.3 Capsular Patterns of Extremity Joints Shoulder (glenohumeral joint)
Maximum loss of external rotation Moderate loss of abduction Minimum loss of internal rotation
Elbow complex
Flexion loss is greater than extension loss
Forearm
Full and painless Equally restricted in pronation and supination in presence of elbow restrictions Equal restrictions in flexion and extension
Wrist Hand Carpometacarpal joint I Carpometacarpal joints II-V
Abduction and extension restriction Equally restricted in all directions
Upper extremity digits
Flexion loss is greater than extension loss
Hip
Maximum loss of internal rotation, flexion, abduction Minimal loss of extension
Knee (tibiofemoral joint)
Flexion loss is greater than extension loss
Ankle (talocrural joint)
Plantarllexion loss is greater than extension loss
Subtalar joint
Restricted varus motion
Midtarsal joint
Restricted dorsiflexion, plantarflexion, abduction, and medial rotation
Lower extremity digits Metatarsalphalangeal joint I Metatarsalphalangeal joints II-V
Interphalangeal jOints
Extension loss is greater than flexion Variable, tend toward flexion restriction Tend toward extension restriction
From Dyrek. DA,'iO p12 wIth permission. Capsular patterns are from CynaxSE> and Kaltenborn. 7~
01 other hip mOllon::o. will not be affected. This i!> in COntra~1
to the capsular paltem of the hip caw~ed by diffu::o.e joilll cap:-.ular fibro~i~, in which there i~ lo~:-. 01 pa\&lve Internal rotatioll. f1~>.ion, and abduclloll.
dju~lon or
is not I reco eoonition of a noncapsular pattern •• TIlesoe enough to direct appropriate tTeat~enL Info~matlOn.gamed from Ihe palient history, observatJo.n, palp~t1on. acttve and . s ROM end-feels tests, pa siv e . ' resisled IsometriC muscle . joint mobilily testS. and special tests must be mtegrated to delennine the most likely cause of the noncapsular pattern. For example. both chronic shortness and acute strain of the iliopsoas muscle may result in a noncapsular patte.~ of limited passive hip extension. However, those conditIOns will present differently in tenns of patient history, pain durin2 active and passive ROM, end-feel, and resisted isometri~ muscle lests, and will require different treatment approaches.
Accessory Joint Motions If passive ROM is found to be limited or painful, an examination of arthrokinematic motions in indicaled, Arthrokinematics refers to the motion of joinl surfaces, These motions, often called accessory or joint play molions. are used 10 delennine joint mobility and integrity. MacConaill and Basmajian 82 describe accessory joint motions as slides (or glides). spins. and rolls. A glide (slide) is a translatory motion of one surface sliding over another. A roll is a rotary mOl ion similar to the bottom of a rocking chair rolling over the floor, A spin is a rotary motion around a fixed point or axis. Accessory molions usually occur in combination with each other and result in angular movement of the bone shaft, or osteokinematic motion, Kaltenbom 74 refers to the combination of translatory glide and the rotary motion of rolling as roll~gliding. The combination of a roll and glide allows for increased ROM by postponing the joint compression and separation that would occur at either side of the joint during a pure rolling motion. The direction of the rolling and gliding components of roll-gliding depends on whelher a concave or convex joint ~urface is moving. H a concave joint surface is moving. the gliding componenl occurs in the same direction as the rolling or angular movement of the shafl of the bone (Fig. 6.1-1). For example. during flexion of the knee \\ ilh the femur fixed. the shaft of lhe tibia rolls posteriorly \\-hile the joint surface of the tibia also glides posteriorI). If a convex joint surface is moving. the gliding component occurs in the direction opposite to lhe rolling or angular mmement of the shaft of Ihe bone. As an example. during abduction of (he glenohumeral joint. the shaft and humeral head roll cranially. "hile Ihe contJ.cting anicular surface of the humeral head glide. caudall). In lhe human body. roll-gliding is by far the mOM frequently occurring :lrlhrokinematic morion, although (here are se"eral tn~lance~ of pure spin motio~. An ex~mple of a spin jomt motion '''auld be supinalion and pron<JIIOIl of the radius at the humeroradial joint. Normal arthrokinemalic (acl:e~~ory) motions are neces~ary lor full and symptom-free oSleokinematic motions, The careful .... "'X·\· . f mlllalion 0 acce~sory mOl ions helps (0
17;
AflQUldl
Table 6.4 t\CCC""ory Joint T\.1otion Crades joint Status Grade
k2~I",
movcmr>nl
\ m::ment
,
0
RolI-:--.
ConSiderable hypomoblilly
'"
Slide
\1.'\
2
Slight hypomobihly
3
Normal
4
Slighl hypermobility
5
ConSiderable hypermoblilly
6
Unstable
Adapted from Wadsworth. CT Manual Examlnatton and Treatmenl 01 the SpIne and Exlremltles WillIams & WilkIns, Baltimore. 1988, p 13, wllh permISSion
B
A Figure 6.14 1)I,Lt.:',L1ll111.llll" n.'pn:,cnlitIHln
Ankylosed
ollhc t:on(ilioning., relaxalion of ~ur rounding mu~de .... 'ltabdintion of one jOlllt ... urface. and mohilil.erted by a muscle or group of mu~c1es to overcome a re~I,"tance In one n1.l~imal effort. Clinical method~ of J~len11lning l11u~c1e \trength include manual mu~c1e
PIl\~i('al
17R
RL'hahililittioll
IL::--II nl.!, 11.Hlll- he III dynanHl11ll' t r~. ~l11d I:--o~ 1nL: [ic d) n~llllllnl l:lr) Ol'pl'ndlll~ t)!l ;he p,IIICIlI. (Ilher dl~lracll'f1'[1C" rdah:d III IlW'l'!L' pLTll)nnann' nu) :lI,n hl' le'[l'd. MI/\ric /Wll'cJ" i, \\'or~ pfllllllccd IKr unit of lime. l)l' the producl of :o.trcnl.!lh and :--pcl'd. Mu~d(' cnduralH.:c 1'\ lhl' ability of lhe 11w... 10 contraCI rcpl'~lIcdl) O\('r time. In addition 10 thc:--c qu,Hltil~HI\'e Illca:--url"'. Ihe patll'nt':- 4ualitalivc n:'pon:--l' in lem,... oj chan~e" in pain durill~ rc~i"ted i~o mt.:lric h,: ... ting i", illlport:llli in idcrllifying lllusculolendi-
Table 6.5 Results of Resisted Isometric Testing ~.
.
.
•.
Strong and painless
There is no lesion or neurologi· cal deficit involving the tested muscle and tendon.
Strong and painful
There is a minor lesion of the tested muscle or tendon,
Weak and painless
There is a disorder of the nerv· ous system, neuromuscular junctton, or a complete fupture of the tested muscle or tendon, or disuse atrophy.
Weak and painful
There is a serious, painful pathology such as a fracture or neoplasm. Other possibilities include an acute inflammatory process that inhibits muscle contraction, or a partial rupture of the tested muscle or tendon.
rll'
nOll:-- Ic"'iol,....
Resisted Isometric Testing During the perforl1lJIK~ of active and pa'i:--ive ROM testing. a palient may complain of pain. The palient history. location of pJ.in. and Ihe paltern of painful motions may :--UQ2est a Ic~ion in contractile ti~",ues such as muscle or tel~(lon., and their imertion:-- into bone. or involvement of inert tissues ~uch :h the joint surfaces. joint capsule. or ligamellt:-., Re~i~ted i~oll1etric testing can be used 10 further clarify which type of ti~~ue. contractile or inert. IS involved. Increased pail! during a resisted isometric contraction. cau~ed by shortening of the muscle and pulling on the tendon. help~ 10 confinn the involvement of contractile ti~sue~. Sometimes more pain i.. . fell when the contraction is rt'lea~ed and lengthening occurs; this would still be considered a positive finding for a lesion in contractile tissues. The lac~ of pain during resisted isometric testing, pain noted with limited accessory joint motions, a capsular pattern of joint restriction, or particular end-feels during passive ROM and acces~ory joint motions help 10 confirm Ihe involvement of inert tissues. For example. bicipital tendiniti~ would be painful during resisled isometric testing of elbow tlexion and shoulder flexion. An adhesive capsuli(i~ of the glenohumeral joint would be painle",s during these ~ame maneuvers. Resi~ted i~ollletric testing IllUst be performed carefully to slress particular contractile ti,>sue while avoiding ... tres~ to surrounding inert ti",,,,ue. The therapi~t ,,>hould place the palient's joint in a po",ition Illidway through the ROM, ~o that Illlllimal temion is put on inert ~trllClUfes. The body part proximal to the joint being te~leJ mu~t be \\ell stt to allow the patient to relax and avoid ntrancous Illu:-clo.:: wb~titutiu1l'>. Then lhe patient i~ a~h.cd to hold thl~ pO,>lllon while Ihe therapi",t graJually applie~ resl~tance. Joim movement IS ,trictly avoided. Although ",ume cumpre.,:--loJl 01 artICular "'lIr1~tn:", will occur during tilt: I~ometrlc contrat'!ton. lhi., does nOI lI,>u,dJy pre:-,cl1I a prohll::m in lnterprellng Ihe rc,>ulh. HO\\t:vl.:r. a bur~;1 1tory and the resul!>; of sensory, coordina[ion. mOlOr control. cardiopulmonary. and electromyography te~ting will help clarify findings as well. Cyriax and Cyriax 56 a joint po~ition until the Iherapi:-.t gradually 0\ erpov.er,> the patient and an eccentric cOlllraclion begin!', 10 OC'l'ur. Both method" ,>ugge~t that lhe break te ... t occur~ at the end of Ihe ROM \\ hen testlllg one-joint mu~cles. and at mid-range v. hen te.ample. to te ...1 the ~trenglh of Ihe Illp abduclors lhe patient \\ould be po. and machine a\i~. \tabiliz3tion of proximal bod) pan'> . and gravity correction are needed. Several practice triab ollhe motion 10 acquaintlhc patient with rhe equipment and le~ting prolocol i~ helpful. ,md at leasl one to three ma\.llnallc"l repetilionl) ...hould be Ikrfomlcd prior to recording mea'lurcmenh. 151 I"~ It i... Important lO note thai IOrqu~ \ alue ... \\ III var) \\ ilh t) pc of mu~cle conrractlons (i ..ometnc. t"t)llcentnc. eet'entricl and change:o. In \clocity ~etllllg..... JOllll angle. patlenl po... ltion. te ... t tnal .... re ...' IIlter'vab. p;Jllent kt.. dbucJ.... Jnd prdo;'ld. d~lInp. and ramplllg m,lehill!." ... e((ing~. For example. t:oncentric I.'onIral·tiol1"l \\ ill r..·... ult III lo\\·er lLlrque valuc:lo than i~orne(ric l·Olllracllon III 'hL' ... ame l1lu ... cl~ group, \\-Iuk eccentnc tulllraLllon \\ illll:..uh In high~r tor4u\" \alll"S than I~omt:l~ nc 1.."0ntrIgn ulili7c:-, ankle do...... iOe\lon. knee extension. and deep palpation 10 elicit calf pain. It is suggestive of deep vein 4 mrombophlebili-,: ho\\cvcr diagnostic reliability is limiled.
185
Table 6.8 Myotomes ,0' i[11
,.,. :lI1g the ill1piHrmel11~ . . hould be Identilled ...0 that Ireatmt:l1l can be hKuscd dnd
;"-~"
-
i; ; .;
> .....•
;.>'
'>
L2, L3
Hip flexion
Iliopsoas
L3, L4
Knee extension
Quadriceps
L5
Ankle dorsiflexion
Anterior tibialis
Extension of great toe
Extensor halJicus longus
Plantarflexion
Gastrocnemius
Sl
From Dyrek, DA 190.
p 76
with permission.
effective. The Iherapist must have a thorough understanding of the pathologies commonly affecting the body segment under consideration. l90 The symptoms and c1inical manifestations of these pathologies are compared to the current examination findings 10 establish a diagnosis.
Table 6.9 Deep Tendon Reflexes
Upper quarter:
Lower quaner:
Evaluation of Examination Finding!>
jj
';,
C5-6
Biceps
Musculoculaneous
C5-6
Braehioradialis
Radial
C7
Triceps
RadIal
L3-4
Quadriceps
Femoral
Sl
Gastrocnemius
Sciatic (tibial)
The degree of reflex activity is graded on a 0 to 4 scale. Grades are awarded based on a predicted response and comparison of responses between body halves. o = no reflex response 1 ::= minimal response } 2 = moderate response 3 = brisk, strong response normal range 4 = clonus From Dyrek,
OA,I90 P 76
With permission
11''\\)1.•1 Kd,.h,111 tum
,,,,,
SPIN-Al NERVE AND MUSCLE CHART
,.
H(
OU-Pt;lUCU ...
uPP£f11
('I"11lI
•
,
'.
v
~
, HIM ..
",r
tllClU ~ I ('f'+
,I
1'1'" 1'_
of.
1 t,ll'~ll
JIN''''.... t'''
.A!Alhould clearly determine the baseline for the patlent\ symplOms. impairments. functional Iimi· lalion.... and di ... abilitie~. This information becomes the ba!lis of the clmical problem list and guides development of 3micipated goals and expected outcomes. The results of future examinations can be compared to this baseline to evaluate the effectiveness of treatment. In addition 10 e~tablishing a diagnosis and baseline data. lhe evaluation of findings should ascertain etiological fitcto~. Unles~ lhe underlying causes of the condition are recognized and treated. chronic problems can be expected. l The therapi~t mu~t not only direct anent ion to the specificall) imohed tl'!iSUeS, but must also think more broadly of physiological unit~ of function and biomechanics. For example. a patient with a sprain of the medial collateral ligament of the knee ma) initially respond well to treatment consi"ting of compression elastic wrapping, ice. elevation, reduced activity, and a protective non-weightbearing crutch gail. However. if the condition is partially due to abnonnal foot pronation. the resumption of nonnal weightbeaTIng aCllvitie':> ma) cause rcinjury unless the alignment 01 the fOOl and leg ilo, improved with orthotics. Similarly. a patIent wllh tendinili~ of lhe ~upraspinalus mu~c1e may react well to reM. l11odalitie!'> applied to lhe tendon, and gentle glenohumeral ROM exercise~. but often also reqUlre~ e\entual ~lrenglhening of the rotator cuff. trapezIU.... and \erralUS tendon. Otht:r II1fonnation that lmpall~ Ihe prognosis and Cour\C of treatment \hould be determined during the e\aluation proce ... ~. The Illude iUld mechani:-.m 01 onset rnu~t be e"tabll hed, Wa\ Ihe on"el sudden. gradually acqUired. or Lttngenu..tl" Generall). Iht' pmgno\ls I~ belIer for a condlIIlIn t,.lltlll J f)Tlh,.p 'f'l'rl Ph" nh'r :::~ 1\, \IN)o, \~ ',II}.1Il < { ,mJ \\ hiit' DJ \It''.I''llrenwIU .,1 J,'"l1 \!I'WIIl\ ('lI"k I" {,ttnlllfll,'lf' (',I \ r \ D.l\ I'" I'tlll.lJdphl.l. ~u'n 'i' \nto:f1.. ,1ll \l .••kna ,.1 ()nht~,l. Baltimore. MO, 1993. 94 Sharrard. WJW' f\luM:le recO\i'f) 10 poliomyelitIS. J Booe Joint Surg Br 37:63. 1955, 95. Bt'a~le}. we Quamilall\e mu,c1e IC!lling: Principle:,> aod application 10 re'tt"an.h and chnical ..ervice". Arch Phys Med Rehabil 4LW8. 1961. 96. Aodrt:!I. PL, cl al: A l'ompari"on of lh.ree mea'J,ure:,> of dbease progrc..,ion in ALS. J Neural Sci I ~9-S:6.t, 1996. 97. Sclmam. S: Rcl.lllOmhip belwc:en IwO meai)ures of upper extremily ....lrenglh: 1\1Jnualmu..cle lc~t comp.lred to hand-held myometT)'. An:h Ph)" r-.led Rchabil73:I063. 1992, Cle testing 10 obJCCII\C "Irenglh meJ~uremen..... Mu...de lene 12:173, 1989. 99. Boh;mnon. R\\" r-.lea\unng I..ncc t'\lt"nwr mUM:lt' 'ttren1i!:lh. Am J Ph) .. \It:J Rt"hdbd 80:13. 1001 1()(1. Nure..u. L. anJ \'achon. J: Compan'OlI of Ihret' method.. 10 ~.:. .. Illu...tular \lrcnglh in indl\ idu;tl... \\ Ith . . pmal cord inJuf)'. SplOal Cord 16:710. 19')!ij t,;,\
lUI Wad...... orlh. CT, el al: Intrdr3tcr rdubl1ll) 01 manual mu:'>C1e lestutg and hand-held dyn;tml"lric l1lu~c1e le..III1(!.. Ph, .. Ther 67: I :,\.. 1987. 102 t-=Ior~~ct" JM. el al IllIrarater re1l:1hilll)-ot n~anual mu\c1e teSl (Medl("al Re.. . earlh CoulllJ Orlhop Spon Ph~ .. Tha 26:192.191)7. 112 Sc"krlwrg. GL: Handheld DYIl:lmOmCll) for r.lu\ck TeCle force meawre1llenh obl;)lI1ed .... Ilh hand-hdd d) namomelCl'!>. Ph}, Ther 76:24X.I'Nfl. 119. Boh.tllnlln. RW: Uppa eXln.:rnilY :'lrength and ;· Ion .IIlJ e" of pertonning a coordination examination of motor function are 10 detemline the: 4
4
I. Muscle aClivity characteri . . lin dunng voluntary 1ll0Vt;:menl 2. Abilit) of l11uscle~ or group.') oflllu . . ck~ to work together 10 perform a ta . . J... or lun(·tional activity J. Le\e1 of . . "-ill and effiuc:ncy oll11O\t'ment ..t Abllil) to lIliliale. control. ,.tnd tennlll:lle mo\cmenl 5. 1ilmn~. ~quencmg. and au:;umq of 1110\ ("ment pattern.') O. Eftc(h of therapeutic and pharm,lcologlulllntenentlOn on molOr IUll( tIOn 0\ er time
a"'' I . .
In addition. d:.lIa from the loorJm:ltiun t'>.nmin;'ltloll 1 [he thcrapi::.t \\ ilh c:::-w.bli~hillg tht:: ol:.tgno.. i.') 01 Lmdl?rl) lllg Impuinnenl::'. IUIKtlonal limil ..tllun .... ..JJ1J JJ\abliil): ,l... .')l.')t
with eSlablishing anticipated goals to remedi3t.e impairments and fonnulating expected outcomes to remedlate functional limitations and disability: and suppon decision making in establishing a prognosis and determining specific. direct interventions.
Overview of the Motor System The motor system can be grossly divided into peripheral and central elements. The peripheral somatic motor sys· lem includes muscles. joints, and their sensory and mOlor innervalion. B The. cenrral elements can be divided into three hierarchical levels to assist understanding their organization as well as delineating the contribution of each neuroanatomical structure. However, this does not imply a strictly top-down control of coordinated movement as each level of the nervous system can influence other levels (above and below) depending on task demands (i.e.. flexible hierarchical theory). Bear et al pro vide a practical description of the three hierarchical levels relative to their functional contributions to motor control as follows: "The highest level. represented by the association areas of the neocortex and basal ganglia of the fore brain. is concerned with STrategy: the goal of the movemem and Ihe movement strategy that best achieve the goal. The middle level. represented by the motor conex and cerebellum, is concerned with /tIctics: the sequences of muscle contractions. arranged in space and time. required to smoothly and accurately achieve the strategic goal. The lowesl level. represented by the brain stem and ~pinal cord. i~ concerned with execution: activation of Ihe mOlor neuron and interneuron poolS that generate the goal-directed movement and make any necessary adjust ments of po.')ture."2l - p 46() The motor ~ystem can also be viewed as having a parallel arrangement. For example. infonll'lUre . .lnU paltt'rn~ 01 1ll00ement and I':> !Inked to dllliLult) Illlllatmg
. ell as erroro;; in the rate. rhythm. and tim· movement .1... w in'? of re'ponses. ... Perlman~1 provides an adept summary ~f the mot~r . . I associated with each of the major anatomiC 111lpalOnen ~ .. . f (he cerebellum as. follows: The cerebellum has rel!lOnS 0
th;ec anatomic divisions that account f?r ~he three ~ypes of dy:-.function commonly seen:. (1) t.he ,m~lme (vermIS, pal.e. ocerebellum). which underlies tltuballon. truncal. ataXIa, orthostatic tremor, and gait imbalance: (2) the hemispheres (neocerebellum - right controlling the right side of the body and left coni rolling the left si?e)..which cont~bute to limb ataxia (e.g.. dysdiadochokinesIa. dysmetna. and kinetic tremor). dysarthria. and hypotonia: and (3) the fK>sterior (flocculonodular lobe. archicerebellum). which also influences poslUre and gait as well as causing eye move* ment disorders (e.g., nystagmus, vestibulo·ocular reflex disruption)."~I. p 216
The following motor impairments are manifestations of cerebellar pathology. ASlhenia is generalized muscle weakness associa[ed with cerebellar lesions. Dysarlhria is a disorder of the motor component of speech articulation. The characteristics of cerebellar dysarthria are referred to as scanning speech (often described as having a one-wortl·al-a-t;me quality). This speech pattern is typically slow. and may be slurred. hesitant. with prolonged syllables and inappropriate pauses. Word use. selection. and grammar remain intact. but the melodic quality of speech is altered. 32 .JJ D~'sdiadochokinesia is an impaired ability to perfonn rapid alternating movements. This deficit is observcd in movements such a~ rapid alternation between pronation and supination of the foreann. Movements are irregular. with a rapid loss of range and rhythm especially as speed is increased. \\ Dysmelria is. an inability to judge the distance or range of a movement. It may be manifested by an overestimation (h~'permetria) or an undere~timalion th~Jpometria) of the required range needed to reach an object or goaL D.\'ssynergia (movemenl decomposition) describes a movement perf0n11Cd in a sequence of component parts rather than a~ a ~ingle. ~Inooth ,Kti\ it). For e>.ample, when as.ked to toudl the inde>. finger to the no~e. the patient might fir~t llt:'\ the ellx)\\. lhen adjuq the po~ilion of the \\ fl~t and finger",. tunher lle\ the elbo\\. and finallv flex the shoulder. As~ nergia I.. the 10'.. of ability to ass~iate mu~c1e~ together tor l..'omple\ mo\'el11t:nt~ . Gail al:l\ia IIwolve:-- ambulatOf) patten1~ thj! typically ~en~on~~rate a broatl ba~~ 01 .. upport. Uprighl .. twlce smbil· II)' b ollen poor and tht': Jm", 11M) be held away from the boo) to lmprov~ babnce (high gu.:.m! po... ition). Stepping pallcTn", .Ire llwguluddenl) \\ hen rt:'''I talll.:/? I... rele'l...ed. The p.lllcnt l11J~ ... lnJ...t' hlln't.'ll nr her-.df or other ohjccb \\hl'n Ih" 1l:.,I.,I..tIll'C I ' fI.--l11()\cJ In'lI1ur l'> .111 IIl\'oluJllal") (l"'llll.lh)l") 1ll00CIlleill re~ulling lhllll altl.:rn.tk I.:OlltracllOlh 01 opp(l"illg lllUM:k grnup':l. DI/1t'1t'llt I~lx'", 1.)1 Ilclllor .. JI"I.: a......LIiI 111\ ol\lIlg muillple JOlllb. Choreifoffil mo\emt:'nl\ l!('1Il0n ...lrdte uTegular liming. are mosl apparent III tht' UE~. JnL! cannot be ,"olunlaril) IIlhibl1ed: as~ociated \\ lth l-Iullllllgh)ll· ... d....l:'a~l~.~l'i
200
Ph,... ical Rehabilitation
Choreoalhclo~bI..,
.1lcml u:-c.-d 10 de . . crihe a mO\cmcnl tll . . onit'r \\ Ilh fealllrt= . . of bOlh chorea and alhcIO"I'i. D) !iilonia (d~ ~lonic movcmCllIS) invol vc\ ,u"tamed Imoluntary contraction . . of agoni~1 and ant3gonist IllU':.:cles~I.\~ causin~ ahnofmal pO:-lUrillg (dy.wmic po:-lUre) or 1\\ i5-ting lllovClllcnh. Mo... 1 COllllllon in trunk and e'-lfemllY mu~cula1Ure bUI aho may affect the neck. face. and \ocal cords. Tor:-ion sp~",m,:> also are considered a fonn of d)SlOnla. \\ ith "'pa~modic torticollis being the 11l0...1 common.J~
Hemiballismus is characlerized by large-amplitude ~uddcn. violent. nailing mOl ions of the ann and leg of one
side of The body. Primary involvement is in the axial abo may be apparent al other bod) parl\ a\ \\ell. ~uch a\ Ihe ja\\: characten~lic of Parkin~on.... di'iea~e. Table 7.1 provides a ~ummary of common coordmub"equent reduction in abiliI) to produce torque."~ In general. Ihere appear" to be d grealer los~ 01 ')trenglh In antlgr~l\it) mu"cleli of the bad.. and LE~ (e.g .. laIJ')..,lmu" dor... i. hip cXlen..,or~. quadricep..,) as compared 10 the UE and grealer los') in pro.\illlal than distal ll1u~de....-" '" SJulled n!ud/UI1IU1W Older ddult, I) pica II) I11m'f" morc... lu.... I). Thl' I' pUI11Cularl) 1::\ Ident lor !a"'~'" (IMt require both ... peed and aCl:ura mal'lI\ il~ Jnd prolonged sil-
1111
111.1\
llllllllt"oUl1..
ULII IlllJ~111.1I1 l
II) Pt~lI
1'k1,llIl.tl.t1t1.'IlIllt:nt III p.1I11l II' , pi ..thllll\ In lull) l"k\ lUl.II ,ttlJu,"nClll' pnlll 11\ I..'\l·
I' lh\
jlllll'llll,d
.ltllllll~ II h pi "..tr.llnn lulltlll ,.1 ,IIHI\I..'ml..'nl 1",I ... ueh as "Grampa" or "Mama:' E:tch individual h:b a uniqut: identity. 7 Request permission to adju..t the volume of the tclevi~ . . ion or radio or to change the :lmount or :lngle of light. R. Maintain eye contacl. 9. Do nOI pretend 10 understand an cider's response. Request confim13tion or clarific~llion of a message you do not understand. 10. Avoid ~pe3kjng to elders as if they were children. Do not u.. .e a singsong voice. baby talk. or give orders. II. Do not ignore individuals or talk about them in the presence of olhers as if they were nOI lhere. 12. Respecl an elder's routines and control of his or her life. Schedule and keep :lppointments at mutually ag.reed-on times. From DeMont. ME ;.md
Pcalman.
NL."~ P'~
with pcmli~"lon.
Examples of Screenings By virtue of their purpose (i.e., providing quickly and eni~ ciently obtained information), screenings are generally perfonned with the patient seated on a finn surface. Although to fully screen some areas (e.g .. the hip) or if several differ~ ent screening~ are planned in sequence. the supine position may be preferable. If abnonnal findings are identified during screening, it is a clear indication for more detailed tesling.
Range of Motion Generally, ROM screcnlllgs involve active movcmCllls. The patlclll is asked 10 t,eJcclJvely move different joints and body segment':. activd) Ihrough their avatlable range. For e>.ample. the patient might bl.,; a,,"'ed 10 tie>.. abduct, and then extend the ...houlder; /lex and extend Ihe t:lbov.; /le>.. t'xtend. nr eircumduL! (lle>.lon-abduclion-extt'n.. ion adductIon) the wn~l; fie>. and extend the knee; pl,lIllurllcx. dor~llkx. and t:IILumduclthe anJ...le. dnd:-.o 1011h. Tu mil1l111iLt'
> I n 1"')\ Idin t • \'crhal dlrectioll>';, the therapIst tllll(' rl'qlllrt::{ I t:>rll)' In front and perform the movements rna\ opl to"l t (Ir,t: . ., '1 I 'I"l" the r'lti~nt 10 "mirror the movements. \\- 111 C' tlrCl: I;" • • rt'{>II'lllllovcmcnl~ can Ix u'\ctlthat combllle A Itcrnal~ Iy. Iln I .. " . motH)ll" 0 I ,e' .."",I • j'oin'" . For example. the patIent might lx' a.."'ed 10 lIl(lIvidu::J1ly place c~lch hand .on the back or lOp of the head. 10 reach
lxxl~
..., ~m n movement ... "ulh ~I\
2()t)
hen htlJll£, a hc;.l\'}' ohjecl). and ml/lIJtll'I' pmlural nmfml (1l1Ot."lic~lllon of \cn .. ory .md lllot(lr \~ \Iem, rel.ltl\ e to ta,~ ur envlronment;)1 dcmamI\) ". a~ well :1\ \ l'>Ion. weight d,\lnbutloll, and po'lUral onentallOn and alrgnment ("CC Chapa'r R fllf a more detailed discu .....ion of po"lUral ('ol1lrol allu balance). A\ multiple ~y~tel11s arc invohcJ III I:'oalancc. ;ll1alysb of equilibriul11 coordlllalion re~ptm,e, \\ III gUide -.election of additional te,'" and mCt", Other \tIJlIl'tlllllll III h...lI.Ulll" 1l1\1uJc· Il'W'Illt' p(l\l/l/(ti nll/I/ol Ilt:'''pltll....: llll'\lr:m~lllllrL't''' .. lith ... .., 1)I,.'rllIlb.llion.. ,t\ll11g on llie
hoJ~ )
/"0(/( /1\'(' IWIlI( 1/)OfOI"\) 1}f!.HllutltWI!IIII (aI1I1CI-
P..lIOf\ Il'''Jll>lht'' III d..·...lablllll1lg ltlrLc" unptl"'l"d 011 Ihl.'
Coordinalion tests address pafient capabilities in four basic motor ta-;k requiremellts. including mobility. stability (static po,,>tural control). COlli rolled mobility (dynamic po,tural control). here. Depending on the practice ~ettiJlg environment, the patient might be observed performing any number of funct iOllal activilies such as bed mobility. self-care routines (e.g .. dre~sing, combing hair, bru ...hing teeth). transfers. ealing. writing. changing position from 1) ing. or ..ining to standing. maintaining a stand· ing. po... llion. \\ alking. and ~o forth. Use of appropriate patient guarding lechniques is indicated during the initial ob~cr\ation. While ob~crving the patient. general infonnalion . act'.l Doe .. occl ud ing vi.., ion alte r tht: qu alit y of motor acti vity? b then:, greate r in vo lvement pro x.imall y or di stall y? h. then: greater l/l\oJveme nt on one s ide: o f bod y versus the otJlc r? • Doc \ the palle nt fa ti gue ra pi d ly'! • h there a c()n~ i.., tency o j motor respon.)c ove r tim e'!
Recording Test Results A genl'ra ll y i.ll.4.:epLt:d format for recordin g re!) ults from Coord ination te"t,:> hu~ nol bct! 1l e!)li.tb li bh~d a nd approachl!~
213
to doc ume nt.alion vary considerably among institutions and indi viduallherapi sts. Owing 10 the nature of the tests and th e wide v"riation in types and seve rity o f deficits. observational coo rdin a ti on form s are nOI hi gh ly standardized. However. an exception 10 thi s are the UE s tan dardi zed tests address ing specifi c compone nt s of manual dexterity through the use of fun c tional or work-related tasks. Some of these tests origina ll y were developed to ass ist with determi nin g if an individual had the needed manual skill s req uired fo r specific employment tasks. Several examp les of th ese tests are presented in the section tilled Standardi:ed Instruments: Upper Extremity
Coordination. Several options are availab le for recording results from a comprehensive examination of coordi nation. A coordination examinati on foml is frequently useful to provide a composite pic ture of the areas of impainne nt noted. These fonns are often developed withi n clinical setti ngs. They may be general (a samp le is presented in Table 7.S), or they may be specifi c to a given group of patients, such as those with brain injuries. U7 In general. these fonns lack reliabilit y testing. Howeve r. they do provide a systematic method of data collection and documentation. In addition , use of the same fonn for periodic reexamination facilitates ease of compari son of changes over time. These [OnTIS fre quently include some type of rating scale in which level of performance is weighted using an arbitrary scale. An example of such a scale follows:
4 Normal pe rfonnance is demonstrated . 3 Move me nt is accomplished with on ly slight difficulty. 2 Modera te difficulty is demonstrated in accomplishing activity: moveme nts are arrhythmic , and pe rfom13nce
o
de teriorates with increased speed. Severe difficulty is noted : movements are very arrhythmi c; s igni1icant unsteadine ss. oscillations, and/or extraneous moveme nts are noted . Pa ti ent un abl e iO accomplish activity.
A score from the rating sca le would then be assigned to eac h co mpone nt of the coord ination examination. An advantage of using rmi ng scales is that they provide a mec han ism for quantifying patient pe rfom1' ..and If1tcrprt:'ldIn'" 01 r\.· ... lIl; ... ~uh .."'yul.:nt n:IC"h ... hould be performcJ hy th", ....tlnt" IIlJI\ tdual 11ll.'~ 'l;tnd.lnli/cd le~b are u'lctul III ph" ldllll': \lOJedl\i.· rnC~I,urt~... of pal 1'-'111 progre ' o\er Ilmc. I Jll' 10110" lilt!- I'" .1 dC"l.npllol1 01 'cwr,t1 of I he ' t(".. h. I hl' if IHt n-/II\I,JI /lund /- utI( tum reo;r (Sammon,
ll\ih"·(IUt·lltl\
Figure 7.4 ..,\1 \KI 11.J1I1 k\l 11I11·m..lIIPIl.11
(\llITh"'~
nl 'nJn.(:om'~
In\. ( IJd.am;i'o. OK \,"01 ".1
\n l"\..Il1ll'lc \\1 a J"X)"luro!!r;\ph) IIhtrument I' Iht.: 5.\1 \NT 1./111 II \' I ('t~Ur()("ulW!l_ IIHt::n1.l110n.ll. Int. Cbc"-.lIna~. OR l('O I" 1 -Ilw ,,~ I\.·1Il I hg. 7.~ 1IlIdudc....1d: ll.lll1JC lor..:e plait' ll~
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Figure 710 Ihc IlIlgl~ area of eNS involvement). Data Imlll the coordl1lJlion e.\al11inarion also alj... i"t wilh e...tablJ"hll1g antICIpated goal ... and expected outcome.... determining a plan ot care. Jnd IdCnllfj ing the effectivcne~, oj treatmenT inter\'~1111011'>. Because ob~crvalionJ.1 coordinalion te ..."" ,Ire not highly ~tandardizcd. there i~ ;) potential for clTor and mi,interpretatioll of re ...ulto:;. Sources of potential error dl, T~ll~·d , 1' I-'nndpk, uf !\It-ur.d IIil·lt'llCe. cd -I M.:GrJv.-Hlil. ~ :.' \\ Y!lr~ 201.1(1. p !-is 3. "fl. P,mt' r LL M,)l or 2 Hlgh.:r ( enle .... . In ('l,h.·II . H (ed): 'ru r"~' l ' ntt" lur i. J Mot B~ha\ 32(4 1.39 1.1000. 62. Capralllc,l. L_ el a\' Fie ld ev.llu:l.I1on of l-yded t::oupkd mu\'emcnb 1)1 h.lIld and fOUl III older indl\ Jduak Gtl'OllIu[ogy S()( (I ):W9. 21')0-1 n ~ I)c,nhh.:r-. J. e l " I: Llppcr J:);,tr~lTli t) l'lertoml:tllce 11.' ... 1 fur the e lderI) i I Ei\IP>\ /: NUmlrll1\t:' UalJ ltnd wrrt"iluc\ wilh \Cil::.orimot<Jr paranJl.'lt:'r!>. ATdl Ph), ~kd R ~ hab l 1 76{ 12): II ~5 . 19lJ5 . M 1I ,lrtlq . A \ A,g.... dllkrcll\.l·~ III du.J· lus" il1lcrkrenct' arc loc'lhLed It I rl·'JX).be-!!l·I1I:"r.Jll011 pnx e'~i" ' , p ... ) ~hol A~1I\g 10,1 );-17. 20lMJ 6:\ Kcldlliin . CJ . DOl1Jhk.ala. ~ \'. and Sll'lJllft,,:h. GE~ -\!=.c rt'I:l.lc:d ddlt:rcll\J:' ttl Ihe lllntrlll of IllUIIlJ"lIl1 IIIlhcJll..:llh "'Iu tor ('(I1l\rlll SI4) 4 ~~, !(lH4 ("of. K,;ld1.1. .JnJ B.lh~!>. PB_ fIoIeOI{'fl 2.lJIg whi1l' ... .ul.U Ig., Ind(.-.l-.c Itt ,jU.1I· I'h~ I'mts trom }utmg ;WUllho..xt hJ o ld Jg~' P,)dl,)1 \~ln,g l '\I')-' 17,:ooU hY \kGlbbo.'lI. ( "t'y. 8 : Torque-velocity rdJllOn, hips for the knet' e,'ell\{)r, in \\omen III the ir 3rd and 71h decade". Em J Appl Ph )~ loI6() : 1 87. 1990, ~4 K:llIm:'ln . DA, Platt•. Cc. and Tobin . J D: 1111.' roll' of mu!>i.'1t: lo ... ~ ill tilL' :Igt"-related dl....c llnc of gnp \ trenglh: Cro",,-sec\lonal and longi tudinal pt:r"peclIw!'>. J Gcruntol A Bioi SCI Med .t5 : M82. 1990. S5. LlI1dlc. RS. ctlll ' Age nnd gend('r compan . .ol1!> of mu.'>c!e strength in 654 \\omt"n and men aged 10-93 yr. J Appl Ph y~101 83(5 ): 158 1.
1997. S6. BonL. WM ' Dlsu!le and ag lilg. JAM A 2.t8; 1203. 1982. 157. C raik . RL 5cn ... orimotor dUll1 gc~ and adaplalio n in the older adult. In G uccione, AA (cd): Gcnalrir Ph) ~ I c al Thc rap y. Mo ... by- Year Book. 51. Lo ui.'). IY'l3 . P 71. 8M G flIll b~ , C , et .11: Morpholof) ,md ellL) matic capllci ty in ann and leg mu!'>t1(' ... 111 71:\--8 1 )car old men and women. A~ t a Phys io l SCand 115(1J:12S. 11J1S2. tN. Stl.'imach , GE. and W,)nhi n!!ham . 0 ; Scn ~on' mOlQr deficlI~ rel:1ted 10 po,lUraJ q3bilit~ . CJi n~ Geriatr Med 1:679. 19M5. 90. Wellord. AT: Bet\\ een bod d} c hang.:.'> and perfonnanee: Some po:._ :.ibk rea"on, lor s lo",lng ",ilh age. Exp Aging Re:. \0:73. 19K-l. 91. Splrdu w. WW: Ph}~il· .1 1 filne:;;' . .Jgi ng. and psychommor :.peed: A ret Ie\\. . J G.:ronlOl 35:85U. 19S0. 91. We l "'~, AT: BCi'.'>een bodil) change" and per / onnance: Some po ..:.ible rea:.on~ tor ~IO\'> lI1 g \\. It h :tge Exp Agi ng: Reo; 10:73. 1984, 1}3. AHander. E. t'I :I I: Nonnal range of joint 1lI00't:me1llS in ~hou l der. hip. wmt and thumb \\ ilh !lpec ial reference to ~ lde : A COl11pilri ...o n bemeen tw,) populat ion,>. lilt J Epidt:l11iol 3(31.153. IY7-l. ')4 Roach. KE. and Mi le". 1 P: Norm al hip and km:t: active rangt: of mOllon "nle rd,ItI'}lh hi p to :lgt'. Ph ~ . . Ther 7 1(9 ):656. 1991. 1)5 J :'III1':,. B. and ParJ..er, AW: ACII \e ,md p:'h ~ J\'e: mohllit) or I()\\ er 111110 Jumh III clderl} men alld women Am J Ph y~ Mt'd Rehahll MII.t I: 162. J'IXI) l)() DIF.tbILl. RP, and Ema"ithi. A Allin!! and the methaJ\I~llh und~r1 } In).!. head .tlld I>mtural COntJ'OI dun ng V01UllIdT} mOHon . Ph)'!) Ther 77~-I5K
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l-ttl kh.~'tl IHI 1;)1 \n ol·'t:dl\t" lIld 1.mJ.ll'"JJll.:ion making for acquisition of a !otkill requires activalion of the highest level. As skillieaming progresse!>. control is systematically shifted to lower level processing responsible for motor programming. I Damage 10 the eNS imerferes with mOl or function proces!o.e~. Lesions affecling areas of the eNS can produce ~pecific. recognizable deficits that are consbtent amona e patients (e.g.• patients with upper motor neuron syndrome). Individual differences in eNS plasticity. recovery. and funclional oulcomes can be expecled. In condiliol1!ot with \\ idcspread damage to the eNS (e.g .• traumatic bram injur), the re~ultant problems in motor funclion arenumerou.... complex. and difficult to delineale. An aCl:uratc piclure of the ~cope of deficih may not be readily apparent on inillal exammation. A pn)Ce... ~ of reexamination mer time Will generally yIeld an under...tanding of the pallcnt' ~ perfonnance capabililie\ and defiCJI~. The comprehen\l\"c examination focuses on dellncallon of impamnen...... tunc~ tional limitations, and di~ahIlJlie~. Tho...~ Jmpalfl11enh that directl) impau on funclJon ~hould be dearly Identllh.'d
AntK'lpiJlcd ~!:O;ll-,. cxpcclt:d outcome,\. and plan of care
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Examination of Motor Function An C\3mlllalion of mOl or function involvc~ three componenb: (I) pallent hl ... tory. (1) a review of relevant syMems. and 0) 'ipccific IC:-.t~ and mea~ure~ that allow fomlulation of the diagllo~i .... prognosis. and plan of care. ~
Patient History During the palienl/c1ienl hislOry. infol111ation is gathered on: (I) general demographics: (2) social hi>tory: (3) em· ployment/work (job/school/play): (.J) living environment: (5) general health status: (6) sociallhealth habits; (7) family history: (8) medical/surgical history: (9) current condition(s)/chief complaint(s): (10) functional status and activity level: (II) medications: and (12) other clinical tests. Information is obtained from the palient and other inter· ested persons (family members, significant olhers. and caregivers). If the palient is unable 10 communicate accurale and meaningful infonnation, a~ is frequently the case with injury to the brain. data mu~t be gathered from other sources (e.g.. family members. caregivers). A review of the medical record can be used to verify and triangulate data obtained from personal communicalions. Often. the medical record of a patient with pronounced deficits in mawr function (e.g.. the patient with Iraumatic brain injury) is filled with volu1l1e~ of dala Ihal can be unwieldy and diffi· cult to sort through. The Iherapisl can benefit from (he applicalion of a framc\\ork. to idcllIif)' and classify problel1l~. The disablement model. focu"lIlg on impainnems. functional Iimilations. and dl'"abilitles. provides such a useful framework :.IIld i~ an important elemenl of the American Phy\ical Therap) A ......ociation·s Guide to Physical Theraf'iJr Prau/ce.... (See Chi.Jpter I.)
Systems Review ': ~~ \Icmo;, re\ ic\\ "en c\ the PUrpi.hC of a ~creening exammatlon: Ihm i~. a brief or luniled c,xaminatlon ot body sy~ lems. The phy!l:\ ere COllllll Ullllallon .Int! cognitive il1lpi.linl1enl~ will be unahlco to Illllo\\ llrclll(Hh I',.' . many •.lIll! cooper~uc \\ IIh IIldt\ Idual 1l.''\1\ l )1 Ph >'\Ilnu feehng'!). Obtundaliun rrlJI .u:qUlrcd Jher a br:.lln m...ul! Retrograde amnl~,ia n.'fl"f' tuthe lflahllJt~ 10 rt'mcmtx-r pre' 10U\ l('am~ Ill!! .IL411lrcll prior Itl;t br;lIn in\ult. Pallcnh \.\ Jth delirium (anl1c~ (ontmwtlal ~fat(', l}pll.:ally dcmon\tratc impalrnu:n... In 1I1lmCd'i.tIC ,lI1d STM along \\fllll (;011IU ..100. agitatIOn. JI~OrtenlLtIl(ln. ;md u.. uall) Ilh,\mn, or hallucinallOn'i. P;uicJlL.. \\ uh c1cmCniia demon\tr can degrade memory (e.g" benzodial.epine~, anticholinergic drugs)," Patients who demonstrate difficulty relrie\ ing infonnation will oflen relate that the information is on lhe "tip of their tongue" (the tip of flie tongue phenomenon). Variou.s different \lrategies can be used to facilitate recall of infonnatlon (e.g.. prompting, rehearsal. and repetition). If attC'ntion and memory are impaired, instructions during the e),amination should be kept simple and brief (one-level commands \'s two- or three-level commands). The therapist ~hould structure or choose an environment in whjch distractionl\ arc reduced (i.e., a closed environment) to ensure maximum performance during the examination. Demonstration and positive feedback can assist the patient to understand what is expected. and can be used lO mOlivate and improve perfonnance. Use of any memoryenhancing strategy during an examination ~hould be care· fully documented in the patient's chart. t I
Higher Cognitive Functions An examination of higher cognjtive functions typically includes (I) infonnation and \'ocabulary: (2) calculating ability: (3) abslract thinking: and (-l) constructional ability. I:! The patient's grasp of infonnation and ability to communicate should be ascertained. The therapist should listen carefully 10 spontaneous speech during the initial examination sessionli. The paliem's understanding of spoken language can be detemlined usiog simple tests. Word comprehension can be determined by varying tl1e difficulty of commands, from one·stage to two or three (Point to your nose; Point to your right hand and lift your left hand). Repetition and naming can be te~led (Repeal after me: Name Ihe part~ of a watch). R~ading corn prehension and \\'riling ability can al~o be examined. Patients can demonstrate problem!) with aniculation (d)'sarlhria). e... idenced by speech errors, difficulties \\ ith timjng. \ocal qualuy, pitch, yolume, and breath control. Problems of fluency. word flow without pause~ or break~. should be noted. Speech that flows !:lmoothly but contains errors, neologisms (nonsense \\ords), parciphasias (misuse of \\Drds). and circumlocutions (",ord substitution) is indicative of nuenl aphasia (i.e., Wernicke's aphasia). The
2.l2
Ph, ",iul Rehabilir.ation
I) plc.lIl) demon...lrall" deficit.!> in .1udilOry cOl11prc· hrll,lllO \~ Ilh \\ I.'II-:'Irtll.:ulalcd ... pcech m:lrkcd hy \\ ord suh...lIlUthln'" pCl"ch Ihal " ,,10\\1 and he . . ital11 \\ ith limned \ocahulal") :1l1d llnpaired ...)ntax I'" llldicmi\c of nonnuenf apha,ia (I,e .• Broca .... aph'hw). Aniculatlon iii labored and \\ord findmg difficullu:....lfe apparent. In some ...eltings. f\pcclally Ihe atule ho'\pllal scum!!. Ihe phy,ical therapi"'l 01.1) he the fir\l to become aware of communication deticI". Rderral to a ",peech-Ianguage palhologl~t is indi· Lilted for comprchen"ivc examination and c\aluarion. See Chapler 30 for U Ihorough discus... ion of thi" lopic. To elhure the \alidllY of Ihe physicallherapy exammalion. " is necC'~~aT) to identify an appropriate means of communicating \\ ilh the parient. Consultation with the speech-language palhologisl is essenlial. This may include qmpllfying lI1"lruction~. u~ing wrillen inostructions. or U"'II1£ :l!rcm3te fonns of communication such as gestures, pantomime, or communication boards. A common error is 10 assume thai the palienl understand~ Ihe task at h::md "" hen he or :-.he rcall) has no idea what is expected. To en5.ure accuraC) of testing. frequenl checks for comprehem Ion ~hould be perfomled Ihroughout Ihe examination. For example, the u~e of message discrepancies (saying one thing and gel.,luring another) can be u~ed to test the patienl's level of understanding. Calculating ability can be tested by asking the patient to perfonn arilhmetical calculations. ranging from simple addition (what is 2 + 4?) to more difficult calculations (e.g,. muhiplic31ion-what is 4 times 4?). The Serial 7 Test is also cOlllmonly used. The patient is instructed 10 start wilh 100 and subtract 7 and keep on sublracling 7. More functional test~ involving Ihe u~e of money can also be used (How much change should you get for an i,cm Ihal co~ts 59 ceJ1lS if you give the clerk a dollar bill?). Impaired caJculatlon can be indicalive of diffuse encephalopathy or ps}ehialflc dl'ieaseY Ab')lraci thinking can be examined by having Ihe p3lielll provide illlerprctallon", 10 common pro\erbs (e.g.. Explain IA hat I'" meant by "People in glas!Jo houses shouldn'l throw 'ilone~" Of "A 'lIleh m time sa\es nine"). The thempisl documelll~ If the pattent i~ able to provide a correct interpretation, Palienl" "" ilh dlf1lcuh) in ab"tracI Ihinking will Iypicall) an~v.er by providlllg concrete or phy'\ical interpretations (e.g.... It mean ......lone... are hea\ ier Lh:m gla.'\s"). An alternate le"t I~ 10 ha\c Ihe patient describe slmilaritie~ or difTerence! in ;.Ili gnl11 cnl ~e c o nd ~lry lu nl lbC k tig htness alt er po:-.lural contro l. For exampl e. in standin g anteri or pc lvk til tin g and nex ion of the hips and k.necs are typica ll y tht: res ult of hip ncxor ti ghtn cs:-. Pos te ri o r pelvic tiltin g is as~oc ia t e d with kyphosis ~Uld forward head in " ll1 ing and is t y pi c~tl l y th e res ult of ham string ti ghtn ess. Abno nnal iti es in ali gnment th at alter the center of ma ss within the base or suppo rt p l ~l ce increased demands on the pos tural cont rol sys tem. For ex amp le. the patient \\ ith stroke will stand w ith th e we ig ht d isplaced over the :,ouncl leg and away fro m the affec ted limb. T his pat ient will be limited in the use of nomulJ po~ tural cont ro l strateg ies. T hus. an exam in ati on of the mu sc uloskelet.al system is impo rtan t to complete before examination of other element s of the neurolog ical ex amin:u ion.
Tone To ne is de fined a.s the res istance o f musc le 10 passive elonga tion or stretch when an individual attempt s to maintain musc le rela xa tion. It represen ts the deg ree o f res idual COIl tracti on in no rma lly innervated, resting mu ~c l e. or steadystate co ntracti on. Tone i ~ due lO a number of facto rs. including ( I ) phys ical inerti a. ( 2 ) intrinsic Illechanicale lasti c stiffness of mu sc le and connecti ve ti!)sues, and (3) reflex musc le contraCii oll (IOnic stretch re llexes).r 1 It excl udes res istan ce to pass.ive stretch from fixed Contracture. Beca use mu scles rarely work in isolation, th e term pOSl llral fone is prefe rred by some cli nic ians to dc!)c ribe a pattern of mu sc ular tens ion that ex ists throughOut the body and affects groups of muscles. Tonal abn orm alities are ca t ~ egori zed as hypert onia (increa:..ed above nOim al re!'l ting leve ls). h)' potonia (dec rea:-.ed be low n0 011al res ting leve ls), or d ystonia (impai red or di sordered toni cit y).
Abnormal Tone S past ici t." Spast ici ty is
ia. and loss of postural ~tabilit) Jr~ 31 0 a .,ociated motor deficits In patients 'Wtlh Parl..lI1 ...on d, ea')e. H~
potunia
and naccidit~ are the terms used to define or ab'lCnt mu,>cular lOne. Resi.,tance to p3\sive Illmement I ... dllnJnI~h~d ....trcllh refle"es are dampened or ab..enl. and Il1nh are easil) moved (flopp). HypefC'\temlhlht) lit Joint i~ (ommon. Loner mol Or neuron (1 ~1 '",)ndrome re ult ... from lesions thai affect the anle· nUl hom l:t.'11 ~uld peripheral ner\e le.g., penpheral neumpalh). "auda e4ulI1J. le""ol1, radlculopathy). It pn.x1ul:e, 'l)l1lplllil1... ot dent:a~d or ab\Cllt tone. d~cr~ased or ah\ent r('I1(',\(' .... pare, I"'. mu,c1c fa~il:ulaliom and tibnllatluns '" IIh Jcner\..lllon. ..lJld neurogeni (amino acid or lipid disordel». Dystonia can affect dystonia) as seen spas· ' • on I y One part of the body (jocal. modic torticoUis (wry neck) or Isolated wnter s cramp. SegmemaJ dystonia affects two or more adjacent,~eas(e.g., torticollis and dystonic posturing of the ann).20_Decorticate and Decerebrate Rigidity Significant brain lesions can result in coma with decorticate or decerebrate rigidifY. Decorticate rigidity (abnormal flexor response) refers 10 sustained contraction and posturing of the upper limbs in flexion and the lower lim~s in eXlension. The elbows. wrists. and fingers are held In flexion with shoulders adducted lighlly to Ihe sides while the legs are held in extension. internal rotation. and planlarflexion. Decerebrate rigidity (abnormal extensor response) refers to sustained contraction and posturing of the trunk and limbs in a position of full extension. The elbow~ are extended with shoulders adducted. foreanns pronaled. and wrist and fingers Oexed. The legs are held in stiff ex lens ion v. ith plantarOexlOn. Decorticate rigidity is indicati\t~ ot a corticospinal traci le~101l at the level of dien· cephalon (above the superior colliculu\). \\ hile decerebrale rigidily indicate~ 3 corticos.pinal brainstem lesion between the ~uperior colli\..ulus and veslibular nucleus. Opistholonus is strong and ",u'ltained comraction of the extenl\or muscles of the neel.. and trunk. The patient Jssumes a rigid hypere\.tenJed po~lUre. All of these postures Me 3.~~ociated with e agg.::r3led and severe fonns of ~pa'iliCII)
E>.amination or Tone n eAammatton of tone l.:on.,l'.,p., of (1) mllial ob:-oervation 01 reMmg po\wre and palp~tlon. (~) pas~l\e mOl ion test-
mg. and (1) ,11:1I\e motion te~lmg. VariJbiht) of tone is comm..m. For f\.Jmple. p~Htenb \\ Ith ,pa...ticily can vary In their pre~enla110n from morl1lng 10 afternoon. da)' 10 day. ur e\ en hour to hour dependIllg on 3. number of factors IIlcludmg til \Ohllonal dfon and mo\ement. (2) streSS .md ani\ltl). 0) poSition and IIltera("llon of tOOIC ref1eAe~, (4) mt:dILJIIOlb, (5) gener:.!1 health, (6) environmental lcmpaature and 0) \(.He of eNS JIousal or alertness. In addltwn. unnar) bladder ,>(dtU" \lull or empty). fever and
Chapter 8 "~'(amillation of Motor Function
2.l5
Table 8.1 Typical "altern. of Sp'''lici.y in Upl'cr Molor Neuron Syndrome
Scapula
Retraclton, downward rotation
Rhomboids
Shoulder
Adduction and Internal rotation, DepressIon
Pectoralis major. LatisSImus dorsi, Teres major, Subscapularis
Elbow
Flexion
Biceps, Brachlalis, Brachioradialis
Forearm
Pronation
Pronator teres, Pronator quadratus
Wnst
Flexion, adduction
F. carpi radialis
Hand
Finger flexion, clenched ftst thumb. adducted in palm
F. dig. profundus/sublimis, Add. pollicis brevis, F. pollicis brevis
PelvIs
Retraction (hip hiking)
Quadratus lumborum
Hip
Adduction (scissoring) Internal rotation Extension
Add. Longus/brevis Add. Magnus, Gracilis Gluteus maximus
Knee
Extension
Quadriceps
Foot and ankle
Plantarflexion Inversion Equinovarus Toes claw (MP ext., PIP flex, DIP ext) Toes curl (PIP, DIP flex)
Gastroc-soleus Tibialis posterior
Flexion Sacral sitting
Iliopsoas Rectus femoris, Pectineus Hamstrings
Trunk
Lateral flexion with concavity Rotation
Rotators Internal/external obliques
COG forward (prolonged sitting posture)
Excessive forward flexion Forward head
Rectus abdominis, External obliques Psoas minor
Hip and knee (prolonged sitting posture)
--
Long toe flexors Ext. Hallucis longus Peroneus longus
The form and intensity of spasticity may vary greatly, depending upon the eNS lesion site and extent of damage. The degree of spasticity can fluctuate within each individual (i.e., due to body position, level of excitation, sensory stimulation, and voluntary effort). Spasticity predominates in antigravity muscles (Le., the flexors of the upper extremity and the extensors of the lower extremity). If left untreated, spasticity can result in movement deficiencies, subsequent contractures, degenerative joint changes, and deformity. 'Adapted from Mayer NH, Esquenazi A, Childers MK: Common patterns of clinical molor dysfuncllon. Muscle and NeIVe 6:521, 1997
mfectlon, and J1l~tabolic and/or ekclrolytc imbalance can abo II1fiuence tone. The therapi . . t "hould therefore consider the unpau of each of [he~e factors In I support and 1ll0\(' tht~ lunh. During a pa..,... I\1: Illotion te ... 1. the Ihcr;.lpl~1 ~hould llli.ll1ltain lirm and ..Jo Pallen" \\ IIh 'llrolt: ,how up to a 50 perccnt dccre:I"iC in motor Ullih of alTcclcd c'trcmitieto \\ ithin 2 monlh~ aflcr lJI.,UII.~1 Mu'lclc pC'rf01ll1allCC is abo influenccd by lhe prc:-cllcc 01 other impairmcnI:-i including spasticity. e1isor{krcd ...yncrgi;;tic acti\iIY/I1l:lSS patterns of movcmel1lS (po... lti\c ...ign"l). and/or profound ~cnsory deficit. Researchers in\('-'llg:11ing ~lrel1glh change., in paticnls with !'troke have aho found ill1paimlem~ in strength on the supposedly normal C\lrel1111ie.... ,ugge,>ling bilateral effects of ipsilateral le'lon ... of the cerebraJ cone\.~:! Thc~e findings ca'l doubl a, 10 the \alidit) of u\ing the uninvolved side as a reference for nornlal cOlllrol 111 pallcllts \\ ith hemiplegia. Strength can a)..,o be negati\el) innuenced b) di~u~e (an mdlrell Impaimlem). Atroph., j... the los~ of mu~lc bulk (\\ :tsting). It can occur as a re~ult of Ihe loss of funcllonalmobility (diwse mtOfJlty). LMf\ dl,ca~c (nellrogl'lIIc m}'ophy). or protein-calorie malmUnHon. The therapist ~hould \i~uaJly in~pect the muscles. companng and contraC)ling their !lize and contour. Muscles that look Ilat or COil cave are indicative of atrophy, Compan!'-ons should be made bel\\Cen and wilhin limbs. Is the atroph) unilateral or bilater~ll? Multiple limbs? Proximal or distal" Fmcindarions are random. spontaneou~ twitching of lllusclt' fibers that are \ isible through the !o.km. If pre~ent \\Ith 3troph). LMN d,...ease i"l Indicated. Gir1h mea"lurement.s or \OIUmClflc dl~placemelll measures (e.g .. hands or feel) CJn be u\ed ta confiml \isuaJ 1Il,pection finding~.'" TIle Clinical examll1ation of muscle 'Meng.th and power ulJlize~ q.iIldardized method.., and protocol!-. (e.g .. manual mu"de te'lllOg [M\1TJ, hand-held dynamometer". instrumented '''Iolmetic ...:,lemS). See Chapter 6 for a Ihorough di'Cu"l'IOn of th,~ loplC. Al1aIY"'I~ of mu~c1e timing includIng amplitude, duratIon. ",u\cfoml. and frequency can be obtamed U'lJl1g E~1G (see Chapter Y). Analy,is 01 functional ~rfor!TIanL:e abo yidd ... Important data about !TIU"I('Ie performance. Strength te... ul1g ll1ea~lIrc.., (MMT.", were originally dc\doped 10 C">'J SCI spinal cord injury
:-
p Il4
with permIsSion.
.
_
248
Ph) liical Rehabilitation
Box 8.1 Funclional Task Analysis Worksheel .' d evaluation of the patient's task performance T:lSk analysh begms with an appreciation of normal movements. An ~x~matdlon an te observalion. recognition and interpreca'N' . de Critical skills lOdu e accura is completed ~md a comparison 0 f the d ,,,erences IS ma . . I the movement deficiencies observed , and .. ., fh derlying impairments re ale to . ' I •__ L tion of movement deficlenClel). determmatlon 0 ow un d guide for qualitauve funcuooa ~ . q estions can be use as a II f Th determination of whal needs be altered and how. e 0 oWing u analysis. d" . . b .\ What are the nom131 requirements of lhe functional task bemg 0 serve . I What IS the overnlllOo\,cment sequence (motor plan)? . ... ? :!. What are the initial conditions requi.red? Starting position and 100Ual alignment . .' Ho" and where is the movement initiated? ~ Ho" is the movement executed? . f h k' I 'red for successful completton 0 t e laS . :'\. What are the musculoskeleta components requi . fthe task') Is this a mobility activity? Stability 6. What are the mOlor control strategies required for successful completJOn 0 . activity? Skill activity?
7 What are the requirements for timing. force. and direction of movements? R. What are the requirements for balance? 9. How is the movement tenninated? 10. What are the environmental constraints that must be considered?
B. How successful is the patient's overall movement in terms of outcome? 1. Was the overall movement sequence completed? 2. What components of the patient's movements are normal? Almost nonnal? 3. What components of the patient"s movements are abnormal? 4. What components of the patient's movements are missing? Delayed? , ? 5. If abnonnal. are the movements compensatory and functional? Noncompensatory and nonfuncuonal. tJ. What are the underlying impairments thai constrain or impair the movements? 7. Do the mo\'emenl errors increase over time? ]s fatigue a constraining factor? K. Is Ihis a mobility level activity? Are the requirements met? 9. Is this a stability level activity? Are the requirement" met for slatic and dynamic control? 10. Is this a skill level activity? Are the requirements met? II. Are balance requirements met? Is patient safety evident throughout the ta.';k? 12. What environmental factors constrain or impair the movements? I~. Can the patient adapt to changing task and environmental demands? 14 What difficultiel) do you expect this patient will have with other functional tasks? loli. Whal difficulties do you expect this patient will have i.n other environments? Adapted from Ta~~ Force of the Neurolo!!) Section of AP'TA: A Compendium for Teaching Profes~ional Level NcurologlC Conlent. Neurolog) Secllon. American Physical1llempy A\!)ocirltlon. CAP'fA). Ale\.andna. VA. 20()).
or side to side in a posture (e.g .. in sirting or standing) without lo~ing control. TIle abilil} to ~hift weight onto one co;ide and free a limb for non-\l,eightbearing dynamic activity is also e\ Idencc 01 d} namic postural control (5.ometimes called .mulc-dynarmc £'omml). The initial weight shift and redistributed weightbeanng place~ increased demands for Mabllil} on the \uppon \egmem\ \\ hile the dynamiC limb thaJlengc'!) conlrol. For c\ample. a patient" ith traumatic bram InJuT) I~ po~JtlOned in quadruped and demonstrates difficult} "hen a\l...ed to 11ft eilher an upper or Imlver limh. or lift the oppo\lte upper and IO\l,e:T limb, together. In ..,itling. the patient \l, IIh ...trol...e is un;cur~lon I LOS I. and Ihe lone 01 ~13bl1it) can be ohl,tlned and are \ alld and rehahle mea.. . ure ... ot po"l\lTdll..'ontrol "1-: U... mg Ihl" IIlfunn;.lllon the therapl\l Cdn obJC'ul\el)o deter mme the pal lent'... po...tural ...)mmelr\. \\ IHeh I ... a rdlel'llon 01 thl" ,1Inounl ot \~elghl pbct"d on t'4.1lh to(\{ P,llIenh \\ah a .. ) mlnclf) m1,..'' ' '1;'' p'.: . . .:nh "'Iltl thc t,pf'thlll plobkm h)I~"ndnl J~ .... pon ... t: ... "llh Jill II nl hul '~~J) ,tIlU t·\\.l.~""I\t" ,l;tlldlt ...lI"m. O~n.t1l1K . . I..lhdn\ lJIl ht: I"k'knlllncd b) u... lIl:=!- I U\ 1Il10mlJllon J"J!h:l1h \l, Ilh ddh.. 11 In IllOlor l(ll1lml It"~. lilt" p.lth,'lll \llth IJUhl:J tYrlt .. t1I~ h,t\l' rcJun':l1 LO~ L()~ ,tlld (0'1 iJlI~nmllll arl' .11 1,,1 I)rlc.tll~ "lter~d In l)lh~T p.t1holl'fll,.,t1 .,1ion can be Cll;3m· Illcd b) 1Il~lru((lIlg lhe pJllCIll to n.lvigatc ac:ro... ~ the bu\y ph~~lCal therap~ gym. The ahdlt) to 11.hlhll topo~rarhlL'al dl..,onrnt3uoll \\ III ha\c dillk:uh~ oa\ i~JlIll,g Ih~lr (.'11\ Ironmcm and unJt~r'ltandlllg the reL.ltlOn~hlp 01 one pl..h.:c 10 anoillt'r Somawsen... ltr~ IIlpUh mtlude lhi" cutaneou... and pre'. \un.. l"cn ... .Itll'lh lrom the bod) ,e~lllenh III Hllltact .... nh th~ \uppc.1n ,url.ll.\.' Ii" l' Ihe leel III ... I,tIllhnl.! llr OultlX.J..... Ihlgh .Ind 1t-1.'1 III :lIung I Jnd Illu'llt- .tn...l~ JOIIlI prorno~ n~pllor. throughout the t-,od~ ~nle) prll\ Idl' 1Il10nn,ltl~ln ..tblmllhl rdJll\l.' \)I"H.~nt~IIHln i.lmJ lI1\)\i"Tllent nllhe 00Ortant to consider inSlrumenl ... \\Ilh e...tahh .. hcd Tl"ltabIIJly, valitlil). and ~nsil1\1lty. A ... ummJ.r)' of fUl1ctJOIlJI baLlIlce ilhtrum~nts dl~cussed in thl\ l"hJpler .... pr~e-cntt:'d 111 EVidence ummal) Box 8.2,
The Romberg le~1
T~ll" Rumhu,-: Tc.~,\T i... u"ed 10 dt~termin~ proprioceplive contnhutlOlh to upnght balJ.nce, The patient IS lIl'\lrucled ro \land" IIh feel ln~elhcr. C\", . Ie d'lor "0 10 . o~n I""" I EC) un.l(( _ ro - ,ell.md" . If the p.llle-nt 1.\11, \\ uh EO the le~1 il) over 1l11.: rJllent I... then J. .. ~ctlto ,1 •.Ii1J "llh e~e" C'1o~ed (Ee). In
Functional Balance Grades Patient able to maIntain steady balance without h Pallent accepts maXimat challenge and can h handhold support (sialic) directions (dynamic), S ..... elght ea~lly withIn full range
,n all I
Patient able to maIntain balanca without handh I --- I Pallenl accepts moderale challen,~ 01 0 a support limited postural sway (stallC). . f 1#-' a 0 to malnl In ba a 100, !dynam'cl nee wtu PICking object off I Pallenr able to maintain balance wIth hanohold su aSSIstance (StdIIC). PPDrt, may reqUIre OCCastOOal mlntmaJ Pat:ent dccepls minimal cha/tenge aOI to mdlnld,n bdldnce YlI'lfle ' (d ynam1c) turning headltrunk Patient requires handhOld support and m posItion tstatlc) Patient unable to accept cOdlieoge 0 I
_ ~ ~fare to max,mal aSSistance to maintain
mO\le :.-thout 10
f
s 0 balance (dynamic)
Chapter 8 Examination of Mo'or Function
Evidence Summary Box 8.2 Functional Balance Test In~trument
C on t e nt
Validily
Reliability
Commenls
The Balance Scale (Berg Balance Scale) SergIO!! 1989
Multitask lest of 14 balance tasks common in everyday living: 6 static balance items: 8 dynamic balance Items
Content validity: expert consensus (health prolessionals and geriatric pallents).
Reliability (ICC) Interrater = _9B In!rarater = ,99
High degree of agreement of raters
Individual items ranged from .71 to .99
Simple, easy to administer (15-20 min.): comprehensive
EqUipment needed: chaIrs With and Without arms. stopwatch. ruler. 6-inch slep
----,-
I
Focuses on: • Maintenance of position • Postural adjustment to voluntary movement
Items 1-5 ~ tests of basic balance ability Scoring: 5-poinf ordinal scale (graded 0-4) with specific task criteria for levels ranging from 1 > 0; some items timed Max score
Concurrent validity: correlation with Tinetli Balance Sub test = .91 Barthel Mobility = .67 TUG = .76
Internal consistency (Cronbach's alpha) ~ _96
Multitask lest: Balance sub-test: 9 items (4 stalic: 5 dynamic) Gait subtest: 8 items
Equipment needed: chair. walkway: palJent can use usual walking aId
Focuses on: • Mamtenance of position • Postural response to voluntary movement • Postural response to perturbation • Galt mobility
Requirements: able to stand independently Does not include items on gait or reaction to external stimulus/uneven surface
Predictive: 01 lalts in fhe elderly (hospitals, longterm care, community)
Provides baseline, and outcome data; scores of 45 or below are predictive of falls in the elderly
Content validity: expert consensus
Reliability (ICC) Interrater = ,85
High degree 01 agreemenl of raters
Concurrent validity: correlation with Berg =.91 Barthel index ~ .76
Lacks intrarater reliability testing
Simple, easy to administer (15 min) Requirements: able to stand and walk independenlly
Predictive of falls in the elderly (long-term care)
Some scoring criteria vague: difficull to detect small changes
Provides baseline dala; predictive of falls in elderly: > 24 low risk 19---24 mod risk 18> high risk
Scoring: some items graded can/cannot perform: some 3-point scale with specific task criteria Max score
Strong intemal consistency
= 56
Tinettl Performance Oriented Mobility Assessment (POMA) Tinett)11 5 116 1986
,I
•
255
=
28
-~-
Timed Up and Go (TUG) POOsiadlo and RlChardson '21 1991 Get Up and Go Test· MathIas, Nayak Issacs\211 1986
EqUIpment needed stopwatch, amlChalr, measured Walkway patIent can use AD
Single task test: stand-up, walk 3 m (10 ft), turn around, and return to chair Focuses on: functional mobility SeaTing: timed test Uses 1 practice/3 trials for average score
Conlent validity: expert consensus Concurrent validity: Berg = .81 Barthel ~ .78
Reliability (ICC) lnterrater = .99 Intrarater = .98
High degree of agreemenl 01 raters Simple, easy to administer, qU~k screen « 3 min)
Requirements: able to stand
soc walk independently
Provides baseline and outcome data; Predictive of tails in elderly: < 10 sec. = independent 20 - 29 sec. ~ normal for Irail elderly or dISabled patients > 30 sec. = dependent in mObility skills and most ADL (continued)
256
Physical Rehabilitation
Evidence Summary Box 8.2 Functional Balance Test
(ronunn....)
Instrument
Content
Validity
ReliabililJ'
Comments
Functional Reach (FR)
Single task lesl: Examines I_ard UE reach with shoulder at 90" flexion. teet still
Content validily: expert consensus
Reliabilily (ICC) Inlerrater = .98 Intrarater = .92
High degree 01 of raters
Duncan et aP02 1990
Equipment needed: level yardstICk mounted on wall at shoulder height
Focuses on: • Postural responses related to volunlary UE movement • Examines Umlts of Stabilily (LOS)
Concurrent validity: Duke mobilily = .65 Gan speed = .71
Simple, easy to admini&ler, quick screen (5 min) Requirements: • able to stand independently • requires adequate shaulderROM FR affected by age and height
Scoring: dislance in inches Uses 1 practice/3 InaJs tor average score
MulndirectJonal Reach Tesl (MORT) Newton 1OE
2001
EqUipment needed· yard· SId< wai
agl_.
Provides baseline and outcome data; Predictive 01 falls in the eldeny
Single Iask test ExamJnes UE reach WIth shoulder al 90t fleXIOn, feel stdl--forwards, Side· wards, and backwards
Same as lor FR
Focuses on: • Postural responses related 10 volunlary UE movements • Examines lImits of Slab/llty (LOS) Sconng distance mIncheS Uses t practice 3 lnals for average score
Timed Walkll1Q Test Murrayet aJ'n 1966
EqUipment needed measured waJ. 'Ita, (e,g SO-tl152 mt stopwatch !ape
Tape mart\f:rs al 10 60 and 70 tOOl marks 13. 18 tI· :j 2 1 m measured zones lor acceleration tar~el sPf*d dr"ld OOCeJer. aloon
AD can be ;sed ." needed
Single contmuous lesl rtem Compares self·paced preferreo gall speed and taS! speed Focu.)es 011 • overall gaa speed ldlstance over lIme) • abo 11 to aoapt gart speed • can catcl;lale stnde length Uses 1 pra functioning ~ ProVIdes screenmg, baseltne and outcome data, results reported as Ime taken (S8COndo) 01 speed (distance/sec.) Use at AD IS assoallllld Ih slo..... gart ~
~
Age-relaled 1lOIII1S. • heal1lty young adlMs : 12-1.5 ms • older adutls = O.IH.3 nvs
2~7
Table 8.10 hnclional Reach (FR) Refe...."ce \'alue_ (~OR\15) II~
Ite
20 40 Age
167(,.IQj
'46(,221
9
149(122)
138 (. 2 2)
70-87
132(,16)
105 (, 3 5)
4'
,IK'fl' '" i.lnl~ 111111Hl1.t1 -.v. ,I). Illhe l~ ... t i... po ...· IIIH'" lhl' p.lll(,111 ".Ihh.: III ,,1:Ino \~ nil f:O bUI d~1110n~lral~\ IIk,('.I'l~d 11I,I.thlill) ~H 1.111 ... \\ Ith I C. It h Import.lllt to lell
.1 Ill'k!;III\" h:"-l
thr.: ".lIll'nl \(\U .Ih~ pn.':I'.lfl'U IU\.:JILh hllll or hCI III t;\cnt 01 J 1.111 -\ po,", II 1\ l' Hlunhcr~ le"l I" IIldh.Jtl\ e 01 .1
1o...... oj prllur \\ 1111 p0.,k'rI(lf !.:"o!umll le"ioll' in Ih 'I'm,lll..l,rd leg .. L('n lell ... pondy!.l""'_ tumtlf. tk·gcncr· ,I\ll,' 'pmal Lnrd lh ... CJ'c. ulll.:"l dor....lll ... ' Jnl! p~npher~ll n('ufl)I'Jlh). II un .. \C'.Hilnc ...... ou.:ur, In ;,;l:tlldlng \\ illl EO
pruKcplh'll
'h.tll..·.10
t)l"l"
{e t. th,' p;IlICn! \\llh Lcrchcllar al:l\I" or \~ ... Iihular dy ...• 'II I IUIllllonl Ih..: Roml 'rg le...1 I'" nOI ~Irpropn.lll.:.· n I he . . hJ~n~J R.. mll~rg h; ... t. the Ieet .tr~ pla...:ed In lanJem ~ht:d-h~ II11ml.tnJ lh~ EO 10 EC tonJlli .. \n ... IIII plhCd.
rO..
FUIlClional Rt3fh and -\lultidin.'(lional KC;Jch Test (lit rill/I 110"01 Ri'C/I Ii I e.\1 (TN} \\ ~I'" Jeh'!olXd h) Duncan Jnd L'.. )-\\or~cr ... In pro\ Ide a qUl(,~ "'1. r..::..:n ul balance problem... In "'iIlf b;__d ..1I1Ce or talmg J ... tcp. A ...econd meJ\M uremenl I'" t~~el\ a"o u"'lI1g (he 3rd metacarpal for reft.'r· l'IlLt". 1'111'" n1t:J ... uremL'1ll I... then ...ubtri.lcted from the initial mc.t\url"ment. SC~ Tab!..: ~.I 0 for nonnative \ aluc~ of FR. The ~1/tll/llir(,(('OIUlI /{f!llCIt Te.~1 rMDFN) develupcd by
'\t:\\I01l I.·\.nl\nl lrnl1l tltl' l',1fhl'r H.( .1Ild 1ll1'.L urt: ... hu" ttl ;Hl IOdl\ldu.,1 I. ,til rt.·alh 111 lhe t~lr\".ll~1 h.llk .Jrd ..Inti bl cr.i1 (Ii Il'l IlllH... I or hJd. \, .ml , l' .11.: h Ihl' Il· ...' fl'1 111 )n I'" 11ll" ....lIl1l.· ..I'" I R \\lIh the.=- ~anj..,IIt'" 1l\)... lIl1m Il·\n e.=-d to lk'tl'l t po... lcrlpr 1110\\.·1111.·111 .... 101 1,lIl·r..d JI.·,lell. the r a [J('111 1..ln· .....1",1\ trollithc ".tll ~lIId rcaLilt.' ...... 11It..',,;1\'" lu the righl r.iI1J IhcIIIO ttw kIt I ;,... 1.11 a... ''k'.. . . lhk Onl' praltlCC tndl j\ "Ihl"l'd ll('tort..' Ihl.· ...1.. 111 til Ihr~t..' te ...1 trI.Jl ... The IhcrJpl~t rtTOltJ ... IUlldlllllal n.:ach III Inthe ... for . til lhrt..'c InJI... .u1C1 thell ..th·r.tel·... Iht..' Ihrct: tn.tk rhe amoullt 01 rt.'ach ,\ inlluCI1l'l~d h\. ~c'..:ral I.Kltlr.... IIKllllhnc. 11ll' \1/t.: and hCI~ht of the IIIdl\ldual. gl'ndl~r. agl'. and h..:alth. Tht.: movement ... Iratl:~) lI ... ed dllnng ~I n:~lCh tl:~1 \hould be uot live items are con~ilkred ba~ic balance itel1l~ while the 1~lst nine itcm~
Table 8.11 Multidirectional Reach Test (MORT) Reference Values Meea(Ia+w} Abcne SC ..... o..lwdoa An• • REACH-MDIn' 74
_II.
Forv'Jard
8.9 ± 3.4
>12.2
7.6
94
94
r1,.;il.i~l: d) namlc natanct:,. 1tt:1l1'l .Ire ,ul:'tc"''' 01 bJlan~c and gall. Bala~ct: Ic,l Item, IIKlmk '1I111tg. halanl:e. "IHo-..tand. ,1.II1Jmg nalalllc (nuJ~ed C'r rcrturbcJ. 1::.(', IUnung 360 l. ;mJ
mCJ,urc lIt NHh
'!:Jtil: ,lOt.!
OQ!..U1I/l..'d 1Il1l) I'll}
,land-h)-,II G.lIt 1e'\1 Itl'lll'" mdudc inuiatlon of gJlt. ~ath.
m""c(! "ll'P (Irip or In...... 01 balance). IUnllng. and limed \~,lll.... Some: It('Ill' arc s("(m:u on a IWO-POII~1 :-.cale (LanAannol pcrfonnl. ""orne un a Ihree-IX)im 10 _I ~c~le. and ,orne Itcm' are limed (..~c Appendl\ 0). rhe ongmal PO~tr\ I ""l;ale ha..., n total p4.h:-Ible ..,core of .2 . II \\3.... dnciopcd It.lf u...e "lIh Ihe fnul elderl). e.. peciall) nursmg home rt:"ldcnh \\llh :t propen~IIY to fall. lI7 P,llll:lll .... \\ho ..."(lrC Ic:... :-.than 19 an: (on,idered at high ri..,~ for f.llI!< while Iho,e \\ ho ,core bem et'n I\) and 2-l arc al moderate ri .. 1-... for falh. A re\ I~d fonn. the PO~1-\ I~. indudc~ fi\c addl1I0llalllem~ and ~~ a.. de... lgned lor u..e J .. J predittor of falls Jmon~ communit) th~elhng ddcr!) (~\ Ith a 100al po,)~lble "t:ore ~f -lO1. The PO~tA II wa' Je\Cloped a... an outcome l1lea~urc III ;} frJilt) and injury preventIon (rial (the Yale flCSIT lnall wilh J wlal po~,)lble .,cor~ of 54.1Il\-'t~
(?
Timed Get t:p and Go Tesl The Gel l'l' alld Go (GtC) TeJt de\eloped b~ M,(1
I~ llill IUIlt..lIdfl
\l.:
",I,h
III
"thJu\ .lIuJ
lx' '-1m
1~1i.lhIJJt\
1,1
fllll1o ...... llIU .. n"· .. ~nd \'(I~nJlll'll 110\\ Lm,k'lllih III til..•... · ,lh',I" Inlh.Klh.c till' 11I01", IUnlo.lIl.111 I \,llllll1,i1H\n
(".IHIlIl.1I1l 11'
3 \\ h.llt..•
I
\ ttl
ht.'
U dJ lttr
II nll,[.ll Illn.. II,11l 01
4 1he pr
th,,'
j
~rCI-lIln~' C\JIIlII1.t1IHfl
\r.lIl1.IIIl\~nC' ... 1
.d' \11 .lhn.lO!ulttllh.·
rdh:·, . \lr
... ,
n\"f '\
ma~ IInp.m 1"'1111.11111\1 1.'11I("01 1111\\ l .. n ('jlh ht,;.. (\.IOlllll:tl'
5 [1: .. ...,1
Ih,,'
h~"I ...tIlh.
hoth
l,.,,, ..'''-l
/tt'''''''
(
fllt.,'I(llf
•
'II .... llItl\
1)(.·
uh
2. I ·..... lJhr ,Ih Jnd ;/'llld"d
It
h.:-.4h 'P
,II "I rr
'h;
uu"t
I
III
frat.! ~~J(', Ul\1
• k-.ul11
':.It-thht' of
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PHYSICAL THERAPY EXAMI 1-1, 'Dl'J m..::re.I'oCd lone \\l~,llficd \ ...h".onh I:Kilk _~11n her kll upper e... trrll111) I.l [ I. -lill ht r nght Uppt:r ('\In:mlt) (RL EJ. and ~ In tltllh lo\\,ere\lrclT1llll.'" f3LE". ~he e\hlblt ....d 4+ blL.Heral "ntlc t1HIIU Sht.' .... a-, uJlJ.ble h.) 'III un ..upponed. Dunng Upptl!le-d lilirl!-' 111 11,~nili(H1Jlkha\ lur
Demon..trate-s dlnl~uh) \\ tlh concentratinn and al1enllOn. Ahle to follO\\ simple IfiSlnJClIOO\ tone- or t\\o-le\'eJ command'd but Oi.cJ.!o.lonall) forgeh ""hal IS, a ked of her. ReJction lime ..,10\\ ed a~ Ihe number of cholce~ is
I'
InC'rea~clt.
Ea."lil) Jorge'" '" hal 'the
l't
doing,
A\\arc- 01 \en\or) InpUt tpmpnd.,. \ Ibnuion, light louch) to all c\lr..:mllH.~.... llnable to discern common Objecb placed In either hand
tor
~tercogno"'h dl\Cnmmalion.
Ph)'sical Rehabililation
264
Joint Inte!lrity I1nd ~lobility RLE: plantarflexion contracture (40 to 50°) flexion contracturcs al Ihe hip (10 to 120°) and knee (1010 120°) RUE: fie\or conlracture allhe elbow (10 to 110°) Full PROM in Ihe LUE and LLE.
Tone Incre"ed bllalemll) (R > L). On Modified A\h"orth Scale: RUE and RLE 3: LUE and LLE 2.
Retlex 1n te!lri ty Hyperacti\e. 3+ DTRs RUE. RLE. 3+ bilateral ankle clonus.
Cranial :'\er\e Integrity Dysphagia and dysphonia arc present. ~lusc1c
Perfonnance
Strenglh is decreased in Ihe RUE. RLE. and trunk (unable to test wilh MMT). She is unable to sustain R knee extension during standing.
\'oluntHry ~{O\'Cnlcnt PattenlS RUE moves in panial range. obligatory mass flexor syn· ergy pallem only. RLE moves in flexor and extensor synergy patterns with no variation. LUE and LLE demonstrate full voluntary control with isolated joint movements. Coordination is decreased. Unable to reach directly to an object that is held out to her and demonstrates foot placement problems with the LLE in sitting or in standing. Demonstrate~ problems with coordinating limb and trunk movemenb.
Po"ural Control and Balm,,:c Demon~trate~
good head control III all posi{ion~. mdependentl) for up to 5 l1linule~. Del11onstra1e~ dIfficulty In mamlalning \.\-eighl equall) on both butlod\'l. Tends to h~t to the righl "'Idt" whdt" pl.u.:mg \.. clghl pnmarily on her left but10lJ.. , Able 10 reach to the lefl and for", . Arch Ph~, Mel! l. proille: A PIIOI :-lud). Ph)' Ther 'itl.l(j(jl 1lJ7~. ~pa.'tlul)
27
!8 2lj l(J
:\1. :\2 33 14 1)
6:9. 1984
R: \'anablht~
36 Go.... l.uld. C. el,,! Ag.OIlI..1 dlld aslldg'lflhl .Il1l'rU) dunng \ulunl.tl) uppel-llmb l1l,,\ell'k;nt In p.lllC'nh \l, Ith ~lr"Le Ph)" Tht:r 72.62~ 1'J92
37 Buurbonn.. b. D, t:( ..1 Abt\()nn.t1 ~JMI.d palh,·m ... 01 dbo\\. mu~1t: ...1:I\allo)n III heIlUp.arCllt' hUffl..ulllubjC.. h BUIn II2.S5. 1'J1St)
265
38. Roscnfalck. A. and Andreassen. S. Impaired regulation of force and firing panem of !>lOgle motor uOllS in patients with spasticity. J eurol Neurosurg Psychiatry 43:907. 1980. 39. Knunsson. E. and ManensSOfl. A: Dynamic motor capacity in spastic paresis and its relation to prime mover dysfunction. spastic refle:\es and antagonist co-activation. Scand J Rehabll Med 12:93.
1980. 40. Sahnnann. S. and Norton. B: The relationship of voluntary movement to spasticity in the upper mOlor neuron syndrome. Ann Neurol 2:460. 1977. 41. Bourbonnais. D. and Vanden Noven, S: Weakness in patient.'l with hemiparesis. Am J Occup Ther 43:313. 1989. 42. Watkins. M. et al: lsokinetic testing in patients with hemiparesis. Phys Ther 64:184. 1984. 43. Rothstein. J. tt al: Commentary. Is the measurement of muscle strength appropriate in patients with brain lesions? Phys Ther
69,230. 1989. 44. Bohannon, R: Is the measurement of muscle strength appropriate in patienl5 wilh brain lesions? Phys Ther 69:225. 1989. 45. Frese. E. et al: Clinkal reliabiJjty of manual muscle testing: Middle trapezius and gluteus medius muscles. Phys Ther 67: 1072_
1987. 46. Riddle. D. et al: Intrasession and intersession reliability of handheld dynamometer measurements taken on brain-damaged patients. Phys Ther 69: 182, 1989. 47. Bohannon, R: Test-retest reliability of hand·held dynamometry during a single session of strength assessment. Phys Ther 66:206,
1986. 48. Bohannon. R. and Andrews. A: Interrater reliability of handheld dynamometry. Phys Ther 67:931. 1987. 49. Agre. J. et al: Strength testing with a ponable dynamometer: Reliability for upper and lower extremities. Arch Phys Med Rehabil68:454. 1987. 50. Kloos. A: Measurement of muscle tone and strength. Neurology Repon 16:9. 199:2. 5 I. Rothstein. J. et al: Clinical uses of isokinetic measurements. Phys Ther67:1840.1987. 52. Griffin. J, el al: Sequenlial isokinetic and manual muscle testing in patients with neuromuscular disease: A pilot study. Phys Ther 66:32. 1986. 53. Kozlo\\ski, B: Reliability of isokinctic torque generation in chronic hemiplegic e;ubjects. Pbys Ther 64:714, 1984. 54. Edwards. R: Physiological analys-ill of skeletal muscle weakness and fatigue. Clin Sci Mol Med 54:463. 1978. 55. Cunls. C, and \\'elr. J: Overview of exercise responses in health) and Impaired st3te!>. eurology Report 20: 13. 1996. 56. Wade. C. and Forstch. J: Exercise and Dochenne muscular dystrophy. Ncurology Repon 20:20_ 1996. 57. Costello. E. et al: Exercise prescription for individuals with multiple sclerosis. Neurology Report 24:13.1996. 58. B,lSSde. D: Guillain-Barre syndrome and exercise guidelines. NeurOlogy Report 24:31. 1996. 5Y. McDon and neural control dunng human muscular fatigue. Mu!>Cle Nene 7:691. 1984. 61 Borg. G: P.'»chophy,iral ba...es of pen:eIH~d exenion. Moo Sri Span... Exerc 1~:377. 1982. 61. F1SL, J. c:t al. The Impact of fallgue on pallents with mu.ltiple sclenN~. J Can SCI Neurol 21:9. 1994. 6) Benni'll. R. and Kno" lion, G: O\clVrorL weames!> in partially dl'nervatOO ~L.elelal mu~le. Clin Orthop 12:22. 1958. 64. Bame!>, S: Isoktneli{' fallgue cunes al different coOlractile vt'1ocilIe.' Arch Ph)/> !\'Il'd Reh'lbtl62:66, 1981. 65. Bindl:r·Maclc:od. S, and Synder-/'.1:lcldcr, L: Mu....c1e faligue; Clmical Implication.. for fatigue as~e!>sment and neuromuscular electnclIl ~Ilmulatloll. Phy!> Ther 73:901, 1993. M. Mt Donnell. M. ct al: EhxlflCall) ellened fatigue tQt of the ljuadfl('ep~ fen IOn... mu:.cle. Ph}!> Ther 67;9-l1. 1987. 67 Fugl-Me)er A. The !"'O-'>1-l>truLe henllplC'gu: pallen!. I: A mel!lod fur e\aluatlon ot ph)'lC.:l1 performdIk:e. Scand J Rehabl1 Med 7.13,1'175. bS Van~asll. ALlIe )pan de\'elopmeru 10 fUflCtiooall4bks. Phys Ther 7U7g~.
1m
Chaptf'r 8 i--.."'lm inu(ion of \1otor Function k'N"!! (, ,1'1,11 I \!,,,"ro,c III Ph, ,,;,;,11 Th"- nlTl\ I)I, I~H(C UULICPAI.nh IfelllcllI:,nn, Uli''''''. 1"\11 1
llr,LC ~1 (,lIlnP" H .1Ii111'JI':lll",·. \1 Nt·IJH'~('ell ... c ~ 1~\; rI Mmg In.' Or.Hn nJ ~ 1'I'I'II"pll \'"Ih,tnl' 1\ \\' II~H\'. l'h,lilddl,hm.
:1'101
I,
11I ~ ~ll.\ I ,ULJ \"I. ,t!~ L. P. Bait>' ( iu,d,,- ," I'h ~ ~ I l,tl 1- \:ln1Hl.lih'fl .md 11 1,11" \ l Lll..lo" nl S lIPPUl(;{lU Wl lh"ln'" "'- W,llo.. m....
Ph,l.uklphLJ
~nll.~
\,~"mt'nl (" tlUh" 1ll1! uft".r ,c\I:rl· lu.'.uJ mju" '\ rl,.(lt..:,II .... ltk lUl""" I J Hn. Jl17:'i I I Itlll,ln, H \ l'l,m. Pen:I:r'LOn . ,IJ\J C~.gntlll.lJ'- A M,mu,lll llr Ih ~ hulll,ltl"" I\ml I rC.l!l1lcnl 01 Ih(' Ncurnlvglcall) Imp.ll rcd Adult. cd ~ SJ.I~~. fht'rnlMe 'd, II~M" Il Slrut>. k. JnJ Bbd,. I 111( :'>, kn l,\1 51,ilt!' L... ,lIl11n,'II .... n In ' eun'hl ~,.".d.:l 1\ l1.l\" , PllII.IJt'lphw. :!OOO L~ h.I"elll~ \\ \llnH,wnlJI,'alc ,\ praclKaimclhoJ rllT gr3JTJ1g tht.: u igmllH' ,'JII' ,'1 r'Utt.:"'" IN III..: dUllC'lolll J P~)lhllitr R c~ 11: 189 . 1'1i5 I~ \I'rlo..c~, R ,lOll D,,,hun J 'nIl! rc-l,tlI(\l1 or ,m.' I1 ~t h (.1 , tll11ull!' 10 r.lrldll) ~.I h,Lbl1futmRllun. J ('limp '\ cll n,)1 P,)cho l 1 8: ~5Q .
111 kntu:U, 11.lIld I'h'nd \1
!l)()~
l~
\\tldt'f. J' Btl,unt'Ifil: :lppn);u;'h tI::m (JllTllual \'alueJ to biological rh'thlll' \nl1\' .'\l:ad~c l '-hi .ll ll . 1 961 If! St~)o."l..m('\'cr. S (tu'H;1t1 Jet.:",on m'l lo. mg b:l~cd on hom~o' tllllC' ,{lllle!," In \\,.1] S t~'dl: Clime.,! DcCI~lIm Mal..lIlg III Ph) "ical nte' dp) IA 0.1\1", Phtladdphm, l l)~:;. p 74. I"' )..,.:111. R. ,Ill'" Rymer. 7 Sp.Nle hypenllnt:i: Mc.:-han" nlS and nll;"urt'11lcnt Ar~h Ph), Med R.:hahLI 70:1 -W . 19$9 110, Bur!".: D "ipJ"IK"~ J".m :.d
BlOnlc.:h Fill! h;\). I"':-'~
2t'1 B"h,mll,>n. \(. \arlahllll} and fC!labtllt) of Ih!! rcnJululll IIt~1 lor ~rJ'tl~'It\ \J~1I1)! ,\ C~l....·\ It l,u!..lIwlH: DynalllulIll:tl!' Ph ~~ Thcr 117 flW, l'}l(r ~1
Leonard. C. Iri" I 'j;-f) l~ Hoh,d,h 13 .'hn"IIII,11 I-'",I\lro.ll Rdlc\ \\,; 11\ II) C 1\11!.. 1~t::.'. 8.dtlllHUC. !'rX
1"
(,JPUk \ CI,J\ r~T!ll1lli\e lei I.·)' pf"tik A pllol ,IUd, Ph) , Tlll'r ~1S'1t)(.]
1111",
d;,.J AgHlIl'l dl1U "nIJ!.!"Hh! .LLII"I) dUflJlJ!, \olull upll24 t'I'I! n Jj"llrb'IfII1,JI' 0.:1.11 o\bl\tl(!U With hC1I1 Ip:lre!>I!>. :\111 J Occup Thl'r 43 :3 1 ~ . 19~9. .. 2. \\Cul.ir f:ltigue Mu,t:le Nene 7;691. }lur..1 balamt' In Igara..h, "1, and Bla~·k. F led~)' \e..!lbolar "nd \hu..1 C.lIllrol on Po,lurt' •.UId Ux.omOlor E4ulhhnum I\.Mfer. B.I'>C'I. 19K5 R1o\ Hcrdl1l.lfl. S \e~llbulJ.r Kt'h,ll'llln..I"n... c ~u 11\lIlg lllioe commumt). N Engl J \led"I!)' 1701. 1988. 119 TlIlelll. M. el a1. Yale "ISCIT Rl,k IJ('lt'r JbJlement '-tTale'!.\ for fJ.llpre\elllion.JAlllGenalrS()I..'41·~15.IW.l. _. 12u Mathia... S, el JI Balaru..e In elt.krl~ pallen", Tht" "Gt:t-up and gIJ" 1{'''1 .-\r\'o Pll) .. Mt:d Rc:hJI:tI: b7·3!'>~. IQ~b I:! 1 Ptl(hladlo. D.•md RII..h.mJ:>\lO. S The luned "l'p dnd Go", A lest of b.61t,: mobllll) lI)r lr.I.! dc"':rl' [>t'f\\)fl ... J -\1Il Gen,ur SOC .N.14~. 1lK)1 I~:!
111 114
1~5.
'I';
" 'II',
a 1m r l h,... J p..tlkul "I r.. ,wJ I'll lur..tl." I".n 'I "m'>rl~ kc IIlU I ,h'llfI~ l,lfl~C" ~ r Br.l!1l h~ ~l) 1\ 1'J77 \1",1 B. ..t1l r~1 ,J .. (,lnd..U\.hzed \t:f"IOIl of Ihe hl.t"'\hnuh: W.i'l.. " ' \;',f lw lJld/\ Itllhlh \l, lIh llt.'urologlc.t1 d 1 . .~ ... un.. Il\'1l Ph, \1 'lhal .1,1 "4 141 .:'(1(1' (IUr,llnkl.. J -I..tl L . I..''oI-rr l; ll ..·lllll) tun, two O'l'r till' Igl' 01 70 \~~~~tl,·\f;~;kli..,r (J! .. u!:t""·4uI..·!lt dh..tblltl} .... En~d J '~Ioo
I~r-. \\1..111 un l cl
J L ".Ill
,.h\\A.. lI\cnl
In
(he ddcrI" "(l.llt dbnor·
Ill.. I11\ rafely j em (2 inches) ( ) I re.tche~ fOf\\arJ blH necd~ supervision ( ) (I 10sC' b'llanee ' , \\ h'en tJylllg. requires e,xlernal '>uppnrt
9. Pick. ."I' IIbj'e"t ' .. "rom I be 11 our from a standing
1 ~ ai"lle 10 Iran ...fer ,>atl'l) Wllh !n1llor u..e of h.IIlJ", ,.i ttl'lt. lollr;llhk'i ...akly '\lIh delmll~ need of hdlld' 12 i.lhlt' 10 {l ..ln ... kr ",illt \l.:rh.. 1 (.'lung .tJlo/nr "'UI""II.:I"\ I'>.on I I tle....\h une per...oll to d~ 1'>1 1...' 0' ..
In... tructiOlb: LiJi arm 10 90"' Slretch out your fingers and reacltfonHlrd usfar as you CUll. (Clinician pl(J(:e!; u ruler ar lite lipS of Ihe oll/slretched fingers\u/yeo should 1101 louch Ihe ruler when reaching.) l!'MUII('(' rccou!ed is from Ihe fingertips H'itli Ihe sub. j('CI /11 the II/OSllol"\mrd pO~l1ion. The subject sltould lI'Ie hoth hands II hen !1oj.\ihli' to l1\'OI(! trunk rotation.
arll/.\. )OU
bed'owl and a (hail
• 0 lH:ed, 1\\ 0 pt:opll: tn ;'
independently and
~tanding
unabk' 10 ... 11 \\ ilhout ,uppon 10 ...econd ...
an.! on. uar
log~lher
So Reaching fon\ ard with outstretched arm while
ahle 10 ')11 30 "C('OIHj.., able to ..1I 10 "l'conJ\
flU' IIOUi'm
pl,ee Icci logelher independently and
stand for 15 'lcconds
able 10 ,it ')afcl) and ...ctufl:h ::! mlnUle ... ~Iblc Iu ,il 2 1l1I1lul....... "Jlh ~uill:n I... ion
a1l1/ft'.H.\
10
...Iand \\'lIh ... upavi~ion for I minute
2 ml1m/{'j )~ ) .1 )~ I I )0
ahk
( ,J ahlc to place fecI
30 ,cum(h \\ rthuut .. uppurt
.t Sillin~ ,dlh back un ... uppurted hUI It'L'1
leep from f·
III Jimn
ChapteT 8 Examination of Motor Function t ) I unal:lle
10 piC'" Up
and need......upen. j,ion \\ hill'
l~ing ( J0
un3hle 10 If)/Ilced... J,siiiiqance to ","cep from ~our
left and right
/oo~ (!lrcef/r
bfhind yOIl OI'er to II/(, rigllf. £.wmlllN /1/0\ 1)/( l cm ohiecr /() lool or direct I) hI "lInd Iht' Juhj(Y{ III ('III 'ow aI!(' a hel1cr [1I';'i/ I 14 klt,-''''"'' bl'hllld trom both 'lide... and weight shlfh \\ell InlrUClioll~: S/lhjc(-, \((lntls l\'i,1t t'\WJllner. Walks down 1-, /10(1I011..1Iu-," (OIt.'a.mredl. hk \'/thj('u Iv "'alk dou" lIl/tAwa\", film (/1/(/ 1It/1J.. ha(·J.. 51th/eo .. hould lise clISlom. 1II \ It ufJ../!/t: lilt!
1 P,lfh It lim.ll'-'d in rl'I..Itiull to line on floor or rug). Ob't'rH: {',\t:uf.,iun uf Vlll' fOUl O\er middle 10 feet of
7. Able tu ~1:Hld nn ont' It'g fur 5 ,",c(;und, (pith om' leg) (I Ufl.1blt.: or h, )IJ lIlIIl J dll~ ohJt· I \l,J:> Inc. IJl 1I10\\,:
. lhlt
llll,thlt- III '>[JllJ \\ 1111 \JIll' totll III hl.:~IIl" I{I j,dl
('(Ill
I -
.2 l,
hum
1J11l1hL[ tIl
r..c.
(J
loot ,>1I~hlh.
~ Idndcm sliJnd II
no hC'"jIK~
I
II . ;:;: un\(ead~ (f,:fJ.h\. '1:U!~cr', I '-IeJ.d~ hut 'leI'" t1i :L7nlllluolh 2 = 'It:.td) Jnd ... ft:p... l.Onlmuou,
"',l/llt ..1.lggt·f11I!:-
2/ points
Timed iremc /0, II
I. Initial;un uf gait (immedi.l({'I.~ i.lftt'r told to "go") o = "nJ h·l:\l I JOI. ~ Or Il1Ulllple ,ltlCmph to ..,tart
'1I:'Jd)
6. rurn .'60
.2
second,
II. Sit down
o=
ull.'>lcady marked .'>taggcring. move!:> feet. m ~elf without grabbing object :2 = stead) \\ Jlhou[ \\al~er or cane or other ~UPP0rl
~Iand 5 ,econd~
9. Reaching up-Examiner holds S-pound weight at heighl of subject's fully extended reach = unable or holds onlO any object I = ~ome staggering. swaying or moves fOOf slightly 2 = oble
Sitlin~
I.
\Iighll)
.2 = able 10 tandem
marh·J Ul.:
l.l"UIl
nllIJ/nh~ll"1.lt~ lin l.tl1~)11 01 u,C'~ \',llking aid .. II tI~hl \\lIholil \\,dl-..l11l! ilh.f
I i"'~t:d ~lt'l) II lip . ur I('\~ (If b~tloJlH'e) (I \ Jnd 1/ ,. lrl" UpfI.Ut: .llklHpl to I
2
h' . hUI ..J.PPlOpf JJ!I.:: ,1I1l.:'illr t lit
tu
rct'O\ a
rCl'O\cr
bJJanc~
1,1 J
lununi!
~hlJ4
"ttl mc' I'
(. Jtmt·cf \4411 Hnt
' .. p
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..
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I:: If.... "ltl~" ... \
6
"h., 1--lll'npklt
rtlf.~
n
l:f'
r
~IKJto
Ifo
~..
.... in a wpar If'
hk"t plMttd on l""'llUT'q'l
CHAPTER
9
-----------------
-
LfA.III; OBJfCTIVfl 1.
[X.,..-ribc the in t\lOlOr 'ene Conduction Velocity Teqing 289 Sen..nry l'IJen'c Conduction Veh>ell)
Te,llng :!91 It Rclk~ 192
The f \\'..lH: 2\}_~ Fflc!.:llo of Age .lOd Temperature 294 f{~p(\rlln~
the
(:\\(, I
L plOp.;:rtIt"'I I.f
U'~'
rr~,entl:t..I
the fir\t report on ek:um:al Jnd Hen e... in 17lJ 1. 1He demonstrJh:tl th.tll,lU . . tl~ .ll'll\'il)' \loa" ~ direct re .. ult of neuronal ":.umublllln ..ntl rt:ulrdc:d potenllah from nlu...de li~r.. 111 'I urf,ice.
Figure 9 .5
AI.!II \\!
IIltl'rdt"l'\roJ c ,>ep.u'<Jthln o f I
A
B FIgure 9.6 Adl\(" del·trod... 31t3chcd 10 ,1..1Il u"'lI1g 3 double"clecl Jclhe.. i\'c "rip.
Figure 9.8 Concentric needle electrodes. showing single (A) and bipolJr (8) wire configuralions.
11111scle~.I' The ch:ctrodc~ arc Ill.tdc with two ~tfands of ... mall~diamet('r \\1re «tppru\imately 100 J,lm). Theo;,e are coaled \\'lIh a jX)l) urethane or nylon insulation and threaded through a h) podennic needle. The tips 01 the \l ires are bared for I to 2 mill and hem bac~ again'll the needle shaft IFig. 9.7). The needle i... IOsel1ed 1Il10 Ihe muscle belly and 1I1lllledi;Jtel) \\, Ithdravm. lea\oing the wire:. embedded in the mu:-.clt-. Becau'ic of the SIll:l1I diameter of these wires. which are a:. thm a~ a hair. \Ubjecb cannot feel lhe presence of the \~ ire~ in the mu ... cle. The \\ irc~ form a bipolar electrode conliguralion that can record from a localized 3rca and e the~ sample motor unll 3Cli\H} from 'iuch a small area of Ihe mUlidc.
--
Figure 9 7 hn~ Wlrr lIldwdhll~' e1el.lroJc:: 27·g .. u~l,.· h)podt'r11111 Iltt"lIll 11"(1IIgh \I.hllh 1\\0 ,lrullO' 01 P()I)Uf~IIl,U1C'UMkd .rt: UlgleJllfcrelltl.tled dX."ll,l,.een electrode har:"l I and .~) and double· d,rkrc:nllaled :'Ilgndl., nhc dilTen:nce' bc:l"'een 1-2 t1lld :!-3). The aUl\ It)" 1\ rel.-urJed Jurin~ Wfhl eXlcnSIQn lB). l>ho,",ing l,.rOln lau.. '" lth l>mgle JlfkrenTldled .':'ll~llal. and dunng \AoTi'l I1n.lon «( '), .. ho.... mg 110 l"fOl>.. ·mJk. a\ .':'llllgk· illlt! double· dllten:mhlled l>lgna" .Ire ot nC.J.fI) equal magnitude (Adapled frum DeLucJ. CJ, (.-J Iv IJe\"'JIl" till ... pwhkOl The ~I","n to IO\C"'t III u:lunclC'rcJ I \1G \'~'h:m" mu,' tx fll;J& h~ uKhUknn}/lhc '1I.!OIh.. .t1u J(kJed t'\~n \CI"U'" lhl." [tIC'rwr •.bpcd 01 the thigh ma) cau~e mmement
.trIlLld. \on1l: !lnlll 01 paddlllg lIflllt'r the thigh. placed pnl \Il11.d .tnJ dl ...IJI to thr electrode,. '''111 help allc\ iale thl'\ pl',,·.."'ure TIlC u')\.' tJf j l"t\nducl1\e clt:ctrolytic gel r l..'mul,I" II'~ Jf!t.'l1t Jppllcd hct",e-en thc melal conlact :md t~ ""'Ill ('Ir Ihe U'oC" of "'11\·er, ..II\rf chlonde eJe'{:trode.... lOa) .tl't\ dC:lTr'~'''C '\u\.h amb:"." \10..1 mo,ement artlfacl ( ·LUT'. Jt .. lgn,11 frNluenl'ie", hclo\\ 10 to 20 hertz (Hzl• ",Ju"ln2 mll1lmal ullerferencc \\ Ith the ampillude of d~ ..,gIlJ!. Oul utollUlg d \\3\) b~schnc. The-.e anlfacb an u ... uall) be dlffill1Jlcd \\ I1h linn fi Jl10n of the elecl~ .,JOd rro~r hlgh-pa .., filtl.'ong ot the ,ignal to atlenuate frtquellLlc, he"."" a ... pt:nfil.-d frequenc). ~uch a~ 20 Hz (llitt \.h"l.:lI~'\ll'tl1 01 IrclIucnq re"poll'f: III th\' next section). \to\Cmel1l 01 ele100 M!lJ 10 cumpen~:.Itc for the uO\\allled noi"ie and signal attenui:ltiol1 that i~ produced by the high rc:,i:-.tance of the skin, Because ..,I..in resis\;lI1cc conlrihutt.:,;: to the impedance mea:-.ured at the electrode..,. gre:Jler input impedance decreases the necu for skin preparation \\ ilh l->urf:lce electrode~,
Frequency Bandwidth The EMG waveform.., processed by an amplifier arc ,ICIUally the f.,ummation of ~ignab of varying frequencie~. mea~ured in here (I Hz = I cycle per "econdJ. A MUAP can be likened 10 a piano chord. which i~ compo')cd of many nOle~. each :11 a different frequcllC) ( or digjtaJ rCltll'(j('T\, ..tore mfOnll,1I10n In ~l lorm that cwmol be read or
Chapter 9 Electromyography and Nerve Conduction Velocity Tests analy/xd without a machine inlerface. The ;Idvantagc of the FM t:lJX' recorder i~ thaI it can store the EMG ll.ignal in it.s oricina.l ~1tl3Iol.: fonn. When using FM recorders. it is importan~ to be a.w;:re that the bandwidth of t.he tape recorder is dirt'etl)' proportional to the tape speed. Therefore, a recording !;peed musl be selected that provides a bandwidth adeqUJle ((II" the ~ignal being recorded. Second. PM recorders have an input dyn:lmic range (typically ::t I V) that cannot be exceeded: otherwise that ponion of the wavefonn that oceeds the input dynamic range will be clipped. This means thaI lhe investigator must adjust the gain of the amplitier appropriately. Too large a gain will result in distortion of the ~i(!.11al due 10 clipping. Inadequate gain will result in poor si~rul-to-Iloisc ratio. I I ~ Dii!:ilal recorders can store data on digital magnetic tape or di~c follo",ing A·to-D conversion of the signal. Their primar) advantage~ are that they avert the noise and distortion problems of FM recorders and they provide data in a digital forma! that can be directly input to a computer for :malysis and di~play. The tidelity of the digitally recorded data is dependent primarily on the perfomlance of the A-to-D convener.
283
Insertional Activity Jnitially. tilt: patient is asked to relax Ihe muscle 10 be examined during insertion of the needle electrode. Insertion into a contracling muscle is uncomfortable. but bearable. At this lime. the electromyographer will observe a spontaneous burst of potentials, which is possibly caused by the needle breaking through muscle fiber membranes. This is called insertional acth'ity and normally lasts less than 300 msec.)() This activity is also seen during examination as the needle is repositioned in the muscle. It usuaJly stops when the needle stops moving. Jnsertional activity can be described a.s normal, reduced. absent increased. or prolonged. Absent insertional activity can be an indication to the examiner that the electrode is either not in muscle tissue or that it is in tibrotic muscle tissue. Lncrcased or prolonged activity may be an indication of unstable or excitable membranes and occurs when muscle is actively denervating or muscle tissue is inflamed. It is considered a measure of muscle excitability and may therefore be markedly reduced in fibrotic muscles or exaggerated when denervation or inflammation is present (Fig. 9.14).
The Muscle at Rest
Clinical EMG The EMG Examination EMG CX:Hllllles the integrity of the neuromuscular system. includl11g upper and lower motor neurons. the neuromuscular junction, and mu~c1c fibers. Testing usually involves observation of muscle action potentials from ~everaJ lllUSclc~ in dlfferenr Mage~ 01 Illuscle contractIon. The EMG signall~ onl) pan of a complete examination. however, which \\i1l mdude J. thorough understanding of the patient'~ hi...lol") and clu\lcal tinding~. For example, the !herapi~t mIght aha C\:tmllle mu:-.cle ~trength. pain, rctlcxe.... sensory function, and lhe pre~ellCC of atrophy as well a~ functional abilitie", in e),(lemit) and trunk lllusculalUre. This dmical c>.3minatlon \~ ill sugge",t which Jl1l1~cle", and/or nerves should be te~teJ.
~~
~.. " .... rllt' • H
•
c
,.. :r
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Following cessation of insertional activity, a normal relaxed muscle will exhibit electrical silence, which is the absence of electrical potentials. Observation of silence in the relaxed state is an important part of the EMG examination. Potentials arising spontaneously during this period are significant abnormal findings. It is often difficult for a patient to relax sufficiently to observe complete electrical silence. However. the potentials seen will be distinct motor unjt pOlt:ntials, whereas spontaneous potentials can be differentiated by their distinct characteristics re.lated to amplitude. shape, frequency, waveform. and sound. One exception to finding no acrivity in normal resting muscle occurs \....hen the needle is in rhe motor end-plate region. Such activity may be reflected as a constant lowamplitude noise (10 to ~O mY) or higher amplitude intermillent spikes which are biphasic. short duration 100- to 300-mV potentials. This activily disappears by repositioning the nec:dle slighlly. Also the patient frequently reports that there is Ic:-.s discomfort from lhe needle electrode
I ~
105mV 50 m!:>
~
.
l2c1 mV 50ms
---,,..-.1....- . . - - [Q,1 mV 50 ms
Figure 9.14 lll(:fl.;:t.,~d (A), nnrmal (8). alld dcue;led Ie) 1I1"CTlilltl ;1\,:llvil) Indue-ed by 11l0V~Ill('nr ... 01 lht' Ill.:\:dle ektlr"dl' (lIIrllh I). TIll' tracing" \\ere ot"ll,uneJ from the fir"'l dor:-,allnl('rO~1>ell~ in a p;11ll:1l1 \\ ith tard) ulnar pab) (Al. Ilbl..lJi" aflll:flOr 111 a Ctmlml ... Uhj~l'l (8), and fibrotic deltOId (l! a p.lllc1e mner\3led by the nerve under "llud,. Allhough the "itimulation of the nerve will evoJ...~ ,cll ..ory and motor llnpulses, only the 010101' fibers contnbUlt: 10 the (,.'UniraCIIOn of the muscle. For example to telit Ihe ulnar nl'ne, the test ml6c1c io;; Iypically the abdUl:tOf dl~111 nllnm11. Other example!'l are Ihe lollowm£~ tor th~ medl3n nerve. the abductor pollil':i!'l brevis; for the hbular nerve. the e.\len ...or digilOrum brevis: and for
Recording
Meehan nerve
electrodes
Ground eleclrode (dorsal surface)
DIstal wrist
crease
Figure 9.23 (A) Body po,ition of subject receiving median ner.'c conduction study showing location of recording and distal stimulating electrodes :md ground. (From Nelson. RM. et 31: Cltnical Eleclrothcr.Jpy. cd 3. Appleton & Lange. Stamford. cr. 1999. p 519. \\ith penni:-.:)ioo.l (8) Bod) position and location of recording...tlmul:uJRg. and ground electrodes for antidromIC median '\.C'n~ry nCf\.t: conduction study. (From Nelson, RM. el al: Clinical ElectfOlhcrapy. ed 3. Applelon & Lange.
Stamford. CT. 1999. P 53-t. wilh
penni~..ion.)
the tibial nene. Ihe abductor hallicus or abductor digiti ffil Illm I.
Small surface electrodes are usually used 10 record the evoked potential from the leSI muscle. although needle electrodes rna)' be u:-.ed when responses are very weak. The recording elenrode is placed over the belly of Ihe te5lt mu:-.cle. Accurate location of this electrode is important to Ihe accuracy of Ihe test. and the belly of the muscle ~hould be carefully palpated. preferably against ~light resistance. A ~econd electrode, the reference ele,·,rQdt>. is taped over the tendon of the muscle, distal to the active electrode. The
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nO the ,dt·\·n. I.KIIlI.ltlng ~nn\I~lcnf me~ ~ " th,' '.I1Ill' "'po.' ' ,p,lu.'" I)urt"l} I11clh,Hllral and does not 1J1l'llh,'llb 11'1 ... rt.'l'll"l'nl .tll\' mU'llt- ,,".II\ 11) lin..' ,llInulll' IllfL'n"I!) "-l.ut-. out !I'm .md 110 "kM I) , ho., 1..\\.... (''I,Un..:,· helore: .Ippl) ing deurodt'\ .\ ground el~ctroJc 1.. plJ.I.:,·d u\l'f D. neutral are:1 ~t\\l·t'n lhe dCl.:lrode, .tIlt! lh(' ",uOlub· til)" .. il('.... u"lI.dl) O'....· r Ihe dOfwm 01 Ihe hand Of fool. llf o\el the \lrl'l or ankle. F"lf Ihe purpo,t'.. 1,)1 I1lu... tr:llll)l1. tilL' te,l procedur\.· 1M the motor '\C\ ulthe meJI:,Hl n('rve "til he Je"ln~J (Fig q~ I, The tt'l'hmt.{lic " bd'I";Jll~ the ,:.ulle for .til nef\e\. e lcpt fur the 'ItC'... of ,llOlULllIOll .mo placement vi the elcun.k.1t:... The fccl1rJmg eh:"lIrode I" l.:tpeJ mer thl: bell} (It the IC\tlllu~,de. Ihl' J.lxIuctor polllri\ hle\ h. antl Ihe refCfe:nn. ektlfvI pHI\.un..t1 10 the JI,,>I.lI UC"I'\.· un the: ul.lf "urL..l~e. v.lth lhl;' c:uhlxtc- olfnled tnv.oJfd th\." Il.'\ l.}lltlnl:! ekl.'lfl}tk... Thl' (Jrli,'0. J.\eragt' \alut'\ ')Cern 10 be fair!) COlbl~tent The motor t\C\ tor the: up(Xr c\lremlty ha~ a fairly 'WIde range. .... llh \dllle" reponed from 501070 m/\e,·. The aver.tge normal \.lrelllity, the Jverage valu!,; i" about. 0 m/.:.cc. Di:'ltal latenCies and aver. ugc noml.tl amplitude" ot M wa\'e~ dIe abo found in !>uch tJble~. bUI the: ...l,,' nlU~t be \ le\\ cd \~ Ith caution, because
291
technique, electrode setup. instrumentation, and patient size
can affect these values. The nerves that are most commonly studied in the upper extremity are the ulnar, median. and radial nerves. Other nerves that have been studied are the axillary, musculocutaneous. long thoracic. and suprascapular nerves. The nerves that have been studied in the lower extremity
include the tibial. fibular (peroneal), and femoral nerves. The sciatic nerve can be examined also using special techniques. The reader is referred to more comprehensive discussions for complete details about the techniques for studying these nerves and for tables of normal values. 56.57 It is imponant to note that the value calculated as the conduction velocity is actually a reflection of the speed of the fastest axons in the nerve. Although all axons are stimulated at the same point in time. and supposedly fire at the same time. their conduction rales vary with their size. Not all molor units will contract at the same time: some receive their nerve impulse later than others. Therefore, the initial M wave deflection represents the contraction of the motor unit, or units, with the fastest conduction velocity. The curved shape of the M wave is reflective of the progressively slower axons reaching their motor unitS at a later time. The M wave can also provide useful information about the integrity of the nerve or muscle. Three parameters should be examined: amplitude. shape. and duration. Any change occurring in these characteristics is called temporal dispersion. These parameters reflect the summated voltage over time produced by all the contracting motor units within the test muscle. Therefore. if the muscle is partially denervated, fewer motor units will contract after nerve stimulation. This will cause the M wave amplitude to decrease. Duration may change depending on the conduclion velocity of the intact units. Similar changes may also be evident in myopathic conditions. in which all motor units are intact. but fewer fibers are avajlable in each motor unit. The shape of the M wave l'an also be variable. Deviation from a smooth curve need not be abnomlaJ, and it is often useful to compare the proximal and dislal M waves with each other as well as with the conlralateral side if indicated. The) should be similar. In abnomlal conditions. changes in shape may be the re~ult of a signifi..::anl slowing of conduction in some ax OilS. repetitive firing. or asynchronous firing ofaxolh after a single stimulus.
Sensory Nerve Conduction Velocity Testing Sensory neurons demonslrale the same phySiological propenie!> a~ motor neurons, and NCV can be measured in a ~Imilar way. Howe\'~r, some differences in technique :.lre neces~ary to djfferentiate between sensory and IHOIOr 3.\ons. Although ~elbOr) fibers can be t('sted using ortlwJnmllc t:onductiun (ph) 5oiological djreclion) or lImit!ronllc
..
292
Ph""ical Rehabilifation
(
~I
( Figure 9.25
~I Rin~
J
electrodes.
conduction (opposite 10 nannal conduction). 3midromic measurements appear to be more common. For the same reason that motor axons are examined b) recording over
muscle. sensory ax-ons are either Mimulated or recorded from dIgital sensor) nerves. This. eliminates the activit)' of
the mowr axons from the recorded potentiaJs.
to the initial deflection. because of the uneven baseline seen wilh sensory leslS (Fig. 9.26). The baseline is more uneven because sen ...ory tests require much greater amplifier sensilivity than do molor tests, and this allows more "noise" to interfere with recording, Advances in the technology of rccording have resulted in the ability to measure Ihe latency of sensory potentials to where to leave the baseline howc"cr. many exarmner... continue to measure to the peak of the evoked potential therefore it is important to know when looking at a report of a test which method the examiner used. Although sensory NCV can be determined in the same way a~ motor CV (dividing distance by difference between latencies). often latencies are sufficient measurements. bec•.IUse terminal branching does not seem 10 be a significant lirniralion. Therefore. the latency essentially represents sensory nerve conduction activity only. Nomwl sensory NCV ranges between 40 and 75 miser. Amplitude. measured with surface electrodes, may be to to 120 J.l V. and duration t;hould be shon. less than 2 msec. Sensory evoked potentials are usually ~harp. not rounded like the M wave. Sensory NCV, have been found to be slighlly fa~ter than motor NCVs because of the larger diameter of ~ensory nerves.6l'1
Stimulation and Recording C tests can be used for sensory NCV tests. or the stimulus ma) be pro\ ided by ring electrodes (Fig. 9.25) placed around the base of the middle of the digit innervated by the nerve. The recording
The stimulating electrode used for malOr
electrodes can be surface or needJe electrode.... SUlface elee· trodes are placed over the nerve trunk. where II is ~uperficial
to the skin. TIle aC[ive electrode i~ placed di ... tajJ~_ and a ground electrode is u5uall) set bel\\ecn the ,tllllulalmg and recording electrodes IOl1hodromic technique). ~ The elccrrode posillon~ can be rever::.ed. mC:.I"ouring antidromic conduction. rf ekctrodc . . itt::. arc con..,i ...tent. th~ latencies l'>hould be e~"'ellllajJy equl\alent III bOlh dlreclion'.), Onhodromito The F re~Jx.m ..e
lIl\'ohcd. "Ud1
h,l\ 31..,0 betH u:\I.'J III
The F Wave
that i..,.
i7td. leadmg to dej-"\{)Iariz.ltion
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om
z ~
(Distance)
,
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MlSo< Velocity)
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(Concluellon velocity)
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L mSo< _ _ _ _ Il.leney)
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om
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(Distance)
om
(D,Slence) MlSo< (Condl,lcuon Velocity)
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~----(laten'iC'J Mca. but 110nlldl eondueWill \doc.:u)- aho"c and bclo\l. In '. ')Ulh ',lh pol)neurop.:uh). 'ote di--crcle single unit interference pattern during ma.\.imal volulllM) conrracljon. (From Kimura.. XI. p ~1 with pemli~lon )
pOlcntiab. positive ::.harp waves. and fasciculations are typ· icall) ,Wl (see Fig. 9.17). With demyelinization. ncl'"\ e conduction measurements \\ ill often provide the most useful d::ua. Sensory fibers may be affected before molor fibers. and significant slowing of sen~ory conduction \·el()(':il} may be seen. The evoked potential \\ ill typically be reduced in amplilUde.
Motor
euron Disorders
MOlOr neuron
di~orders
moM commoilly involve degencraof the anterior hom cells. These include poliom)elitis. and diseases thai are characterized by degeneration of both upper and lower motor neurons. such as amyotrophic lateral s 01 motor neurons. \Vhen single M UAPs can be seen '.\ nh ma:"'llllaJ effol1 by the p::nient the resulting aClJ\ tty is cl ll1llllll
In primary musde dbe \.unc: nl)OIomc:. For example. ahnomlal pOleuliab \Ccn m thl:" f'\lcn\Or mUllodes of the fund rna',- 'jug!!."',,! lIl\'ohemem olll,e: rauul nen'e. Hoy,e\er,lflhe bitep_') brachli 1:-. c".unlneJ Imu....:ukx..utaneou;o, nerve), well d:-o tht." 0PPOI".~. II" polliu:o. (median nen-e), and these mu~( le\ ah\) nhlblt -.ollle Jbnonllal EMG potentials. the ClllllnUJfl fe-alun: ....ouIJ be nm"'ldered the C6 nerve root. nle~l; tllldll\g~ Vo ould ha, e ~lgl1lt1L'JIH Implications for treaI· mCllI plannlllg 111 tr:rm... of Jddre..... lJlg the cause of muscle vo~.ikn~3') or t.1tlguc.
Cbap!e. 9 Electromyograpby and Ne dc::termlned .... 1111I.)ut re-Illm in,g the eb.:trode.. 1
For clinical EMG. the raw signal is displayed to allow visual eXi.lminalion of the size and shape of individual muscle and nerve potentials. For kinesiological EMG. however. the Iherapist is generally interested in looking at overall muscle activity during specific activities. and quantification of the signal is often desired to describe and compare changes in the magnilUde and pattern of muscle response.
Rectification and Linear Envelope The EMG signal can be manipulated electronically in sev· eral ways to facilitate quantification. and to eliminate problems of processing raw data (Fig. 9.33). Through a process called rectification, both the negative and positive portions of the raw signal appear above the baseline; the signal is then full-wave recrified. The rectified signal can be "sllloolhed" through low-pass filtering to produce a linear e'll'elope. which describes a curve outlining the peaks of the full-w3\'e rectified sign:.tl. 19 \Vith the correct type of tiller and cut-off frequency. the linear envelope profile c1o:'>ely follow., mu~c1e tem.ion.~ Many authors and electronic equipment cOJ1lpani~s call this an "integrated" signal. but that is a misnomer. because the linear envelope is ;'1 moving avefi:lge of the EMG output over time.
Integration Another lype of ~ign. t1 conditioning is produced through marhernalicJI jnrcgrar;oll of the EMG signal over the time of Ihl.': cOlltraclion. Its unit~ (mV"'s) represent lhe area under the full-wme-rectitied sigllal. 19 The integraled EMG (IEMGI ,igllal i, produced either through digital signal processing or through the accumulation of electrical enc=rgy on a capacitor. or (·ondenser. lEMG can be proce....,ed III ~n~ral \\uys bee Fig. 9.33). The simpleS! method i~ integration IhruughoLlt (he period of muscular ~CII"II) TIlt' 10Iai ased. Ahern..IIl\t:!). Iht' conllcnfooer I:I'> of median nf mean Ircquenq' p.u.tllldCr\. Rcn'nll} dc\'eloptd Icl'iullljUe, u')lIlg Iimc--lre4UCI1(.) antll),>I,> ,llld
an Increase
111
tude of EMG signals during purposeful actlvlltes. 11le t~ iog of a muscle's response is often of interest 10 detemune the latency of responses between different muscles, or rei· alive 10 some other parameter (e.g.. the command to move) or specific task components. Measurem~nt of EMG onset 10 detennine muscle activation time requIres knowledge of Ihe amount of noise present. An epoch of noise must be recorded before the EMG signal is activated to estimate the noise level. Figure 9.35 provides an example of EMG signal activation for a slowly increasing isometric contraction.2~ The top trace represents the raw EMG signal and lhe bottom trace the RMS value. The amplitude of the noise is represented by the shaded area in the lower RMS time plol. This area was calculated as ± 2 standard deviations of the mean value. thus capturing approximately 95 percent of the amplitude of the noise signal. The raw signal is not sufticiem to mark a clear differentiation between noise and EMG. Using the RMS value. however. the specific time at which the E~MG signal exceeds this noise level for a minimally defined amount of time (e.g.. at least 20 msec) can be detennined. This can be considered the "on" time of the mu,c1e. indicated as III in Figure 9.35.2~This differentiation is c'.>sential to an accurate appraisal of EMG activity.
Nonnalization For many ...tudlrs. the quanllficd Ei\tG signal is used to compare: activit) bet\\een S(''''IOO'). muscles. or subjects. Becau')c of the \ ~mabllit\ mherem In the E 10 signal. and II1rt::nnl.tividual differences 10 anatomy and movemenl. hO\l.e\er. II is nl'lt rea'.>unablc to l'ompare the EMG activity of one mu,>cle to another.. or from one person 10 anorhct Tht'retor~. wme fonn of nonn.lllzarion 1t \ . .IIlIe~ e\ceed the cODb'ol· in tim. ",a) subjeLl~ Jol! 11111"c1n can be compared. .... dnlVH) on differcllI JdY~ l:.Ul be l:on'elated by repeaUnl tht: l.:ol1lrol l:Ol1lral'1l0n at each te... t session. This hdpI
0;
~
302
I'hysical Reh.bilitation
Muscle
EMGSIGNAL
w:wclcl analysis have been successful. in mea.suring ~. 's,'on of the signal assoclf.ltcd With localiZtd e tra I compr;,. . ." . . . . fatigue. t11 However. the actlvltles ~I.ng montlored are ~ ically limited to cyclic ~r repellltVe ~~vement ~ changes in the biomechamcs, of ~he aClIvlly are more ~ les~ predictable.91 This work IS stili under developmenllD various rc!o<earch laboratorie~ and too premature for routine clinical use.
Tuning of Muscle Activity
FA"lGUE
Muscle Fatigue Index
.......
Figure 9.34 Diagrammatic explanation of Ihe change 10 the EMG signal and its frequency spectrum thaI occurs as a result of localiz.ed fatigue. The upper panel represent~ Ihe EMG ~ign:tl sampled al Ihe beginning. middle. and end of a ~ustained contraction. Each sample "window" of data i~ analyzed 10 calculate the frequency speClrum, 35 illustrated by the POWER \crer\ ~ c'" J ....t ... t<Jlltl.lfll Joallht ,\ the length-tension relationships and con· sequentl) the EMG activity. a static contraction may not be a reasonable "control" condition \Ii hen examining movement. Re~archer.. ha\'e shO\\ n that measurements of d)namic EMG y,ill \'aT) \I> Ith different nonnalization procedures, ~ugge~tin{!. that it i~ more appropriate to nomlal· ize EMG activit)' ,wer ~peci.fjc arc~ of l110vemenl. 102 For example. imc:stigulOf' ha\e looked at maximal activity through a rang.e: of motion, and quantified the EMG within arC!a of 10 or 30 . This maximal EMG y, uhin each arc is then used 3.\ the contrul value, and EMG mea~ured during the Ie::.! activit) 1\ nonnalized a.s a percentage of this value at the iolame angle.
The Relationship Between the EMG Signal and Force The relationship bclwc:..:n the EMG signal and mu~c1e ten.!.Ion has been 10 l".h..lll;!t" Ihe 11l0111l;fll .inn
Chapt~r 9 ElcctronnogTaph" and Nene Conduction Velocity Tests
Muscle Fatigue When a muscle exhibits localized fatigue after a sustained contraction. one might e\pect to see a decrease in overall EMG output. The opposite is generally observed initially, ho\\-cyer. Typically. an increase in EMG amplitude is seen initially a~ a muscle fatigues. In an attempt to maintain the leyel of active ten"ion in the muscle. additional motor units arc recruited. and active motor units tire at increasing rates to compensate for the decreased force of contraction of the fatigued fibers. After maxjmaJ contraction. when the entire mOlOr unit pool b supposedly recruited. force declines and EMG amplitude slays conSt.1J1l and e"entualJy declines. The precd . .on anatomical and . billMany c, v. ho have cx pen ~llccd neunJmu:-.tlllar dy~funlllon For example, many rc~eaf(: hcr~ hii\e lumpareJ mUlor activity 111 palt ellh "'Jlh hemiplegw and u1IIIrvi ""U hJ~cb . v. tlh v;JrYlng n:s ult ~. Levin alld HUI -Chan": ... tlldlCd the CO-l'olllr;:u.:tion rallO hemeen plantar anJ dl)r~lne)i,or..,. ,mll ll)uml an Inver..,c correlation" irh lor\,.c III pdrl;"ilL dor,)ll1ex.or'> . Thc) . t1so eSlabl i. . hed that the EMG lIUtpU! Wit.!. rcprot.lullhk over time , :-.lIggc:: . . ti ng thaI till.., tYIk nt Il~ ... ting Luukl be u"l!iul for trad.lIlg ~ h;.tI1gl.! w llh Ire'HmelH .
307
Gowland et aJ 136 looked at upper extremity tasks in patients with hemiplegia. and found that the inability to perfonn these tasks was due to inadequate recruitment of the agonist muscle. not increased acrivity of the antagonist. A similar outcome was obtained in a st ud y of knee EMG signals during isomet ri c and isokineti c exercises, where co-contracti on was low or absent. and was similar for patients and control subjects. 137 These findings support aiming treatment at improv ing recruitment of the agonist. ralher than concentrating on inhibition of the antagonist. A contradic tory finding was obtained in a study of isometric wrist ex tensio n and Flexion, where researchers found increased an tagonist activity with decreased agonist ac tivity in the paretic am1. conclud ing that intervention should address decreasing antago ni st actjvity. Once agai n, we must be cauti ous in drawing any general izations. Perhaps the most important message these tindings provide is the need to attend to potenti al methodological and phys iological differences that mi ght account For conflictin g resul ts. As with any other research method. the consumer must con!'l ider the samples studied, the instrumentation used, the muscles selected. and the operati onal definitions of the activi ti es. 10 deternline whether direct comparisons are warran ted.
Pain-Related Muscle Impairments Clinical research has demonstrated the usefulness of incorporating EMG parameters. such as activa ti on time. amplitude. and median freque ncy. into a classification scheme for musc uloskeletal pain di~orders. By understanding the in teraction between pain and 1110lOr perfonnance, clinicians can directl y address motor impairments that wiJl impact functi on. For example. Madeleine et aJl1!oC examined mechanisms leading to chronic neck and shoulder pain duri ng upper ex tremity activities. They found shifts in patterns of mut-t le synergy <md hi gher EMG frequency components. sugges ting altered mOlor unit recruirment with painful ('011di'-ion~. Wad~wonh and Bullod.. -Saxton I1,) studied competitive ~\\ immers. comparing those with unilateral shoulder injuries and nuninjured mJllcte!.. to dc tcnnine differences in shoulder EMG pal1cm~ with palholog) . They demonstrated ~ i gnifi cant va riati on or delay" in Illusde activation wirh injlu),. indicatin g Lhat temporal recruitment patterns are related 10 injury of Ihi..~ ...ca pular fl)!aTors , interferi ng with co n ~i ~k' nt'y o f muvement. They were abo able to identify Illu ~d~ function deficit.s 0 11 the unaffected "ide. These outcome') . . u ggt'~ t intcnl"nlion ~traleg ies that foeu:-. on function.1i m:-.k .... [If1d tht:" need 10 examine- the effecr of injury On other joilll~ i.1 ~ P[lri 01 [he ~e l'o.1 s/.. :,. Pah~ lI o l cmoral palll h.,o\; al ... o been a mnjor topic of illler~~t for EMG rc"e.lrchers. Quc'ition s. regarding the 1110St effcC'livt exe rt.:i ~t!~. or the role.:- of' various. knl!t! muscles during funuionai aCllvllie~. It:nd thclllbelves 10 EMG study. f\lallY l'IlJ1ir..:ul appl't)acht!~ 10 this prob lem have focused on
308
Ph, !toical R..hahilit3lion
the ralio of al'livily bel ween the v u~ed 10 acquire and proce\~ the "lurfdlC EMG "'gnah. The Icchnique b described In delail 111 pre\ IOUS repon.... I"i~ and is ba...ed on montlonng the l'hdnge In tJlIgue II1dices from EMG sig. nals acqUired ':.lrnlllttable te1'>t frame 10 mamuun ~Wlk PO~IUJc and I\olate Ihe para,:>pinaJ mu~le~; t]) a tor4ue lcrdbJcl.. \~ ':>tern I() maillLam COll.'lotant muscle
Figure 9.37 The Back Analysis System used for acquinng EMG signals and force during sustained isometric extension of
the trunl... A subject is shown positioned in the postural restraint apparalu.'lo with six surface EMG elecLrodes posilioned bilaterally on Ihe lower back. The subject's task is to produce a trunL. extension torque against the scapular pad according to a targer force .'loCI on the visual feedback display facing him. The EMG signals are aUlomalically sampled and analyzed from a computer worL.stalion ShO",1l III front of the operator. The tesl reo;;u!IS are compared 10 a database for c1assificalion of back muscle impairment. (Courtes) of Neuromus(:ular Research Center. Boston Univ('rsil). Boston. MA.) force: and (3) an EMG acquisition and proce~sing system de!>igncd for near·real-time display of EMG median frequency and RMS. With the palicnt po..~ltioned in the device 3!> illllstmted in the figure, \ix acth·e surface EMG electrooes \\, ere placed at anatomical locations corresponding 10 contralalerallongi~simu:"othor'dcis (Ll spinallevd), iJioco~tall~ lumbonlm (L2 spmal le\cl), and multifidus (L5 spmal level) mu:-.c1e::.. A padded strap, cotUlecrcd at each end to a noncompliant force transducer, was placed across the M:apular region for lhi;" subject to push against during fhc tC!oI1 COnLracIIOIl!:>. A monitor Yo as positioned in front of the ~lIhject tu provide for(:e feedback and a target force level. \\,1111,,'11 wa~ bel according to the tCSt prOlOCOI.
Ph~ .. ical
3tO
RehabilitaLion
The test protocol began with a set of wann-up and !ruining exercises in the BAS device. The patient practiced the task or excning i:,ollletri c trunk ex tension at targeted force leveL.;; using the fceuba ck di splay to gui de them. After Ih r.::~c prelim inary trial s were successfully ompleted. the patient was instructed to exert several 3ttempts aI produci ng a maximal voluntary contraction in InmK e>. lcnsion. After a brief rest period. the subject was instructed to follo\\ a "s taircase" protocol in which he had to exen a :,eries of $ustaint'd isometric trunk exte nsions in the dev ice al force levels set at 20. 50. 70. and 90 percent of hi s ideal body weight. respccti,'e ly. Ideal body was calculated from a weight table established fo r men and women according to frame size. 154 The use of ideal body weight 10 standardi ze the protocol task was ado~ted. 10 eli mintHe the confounding effects of subject motIvation whe n previous test contracti ons were based on the maximal voluntary contraction. Each co ntraction was su~t 3ined for 30 seconds. A rest period of 15 seconds was provided between e,ach contracti on.
RESULTS Usin g the "staircase" protocol described , results showed alte red neuromuscu lar control of paraspinal muscles for the patient (Fig. 9.3RA) us compared 10 a control subject (Fig. 9.38B) matched for age. sex. ideal body weight. and strength. The res ult~ are displayed for the force (lower plot). the EMG median frequency (MF). and the EMG and root mean square (RMS). EMG data from the six electrode siles are plolted separately. The example demon strates that despite the ability of the tWO subjects to produce si milar forces. there are obvi~ ous difference s in neuromusc ular control and/or muscle fatigability. A consistent pattern of increasing RMS with in creasing force was seen in the control subjecL whereas in the patient with LBP. the changes in RMS wi th force were highly variab le and asymmetric. Similar results were apparent for the median frequency curves. For the control subject. the MF decreased more rapidly as the force increased. and the pattern was highly symmetric and well
ISO
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roo ,
160
120
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-~ '(Vt;'f that OCcurred ~ a re...ult vi thl'" fall '" ere described as a comblOauon of a")" \hJped transcond) lar fracture and an olecranon type II fracture. Imtial medical/~urgical trealment .... as JOint recofi',lruction by pinning and plates. It 'Ad..., noted that the: pal lent hJd J dlagnosl~ of o...tt:oporosl... priOr to lallmg Atkr i.l penod 01 ImmobihlJtion. the patient noted a marl..ed 10...\ vi mOllon partic.:ularl) ..,uplnation of the fore· l:umfurt and pain. She ill", l:\prc ......td dl -.;,ttl ...h1l.tlun .... ,lh her progr..:~... III ph} ~ltal
therapy and requested further treatment from the surgeon for pain relief and increased ROM. The patient had 0" of supination and 90° of pronation. Elbow ROM w~s 30 10 65° which limited function of 'iimple ta"ks such as bring. ing an eating utensil to her mouth. Following a con ... ult 'WIth the surgeon, a deciSIOn wa~ made 10 insert a IOtal elbow joint replacement arthroplasty. X-ray films taken prior to :-.urgcry revealed \lgnificJ.nl heterotopIc bont: formatiun \\hich .... a~ felt to be interfenng with the patient''i ROM and \\a~ perhaps the ~ource of pain. Follo\\ ing the towl jOIl1t replacement. the patient made ... Iow but steady progre~s. The .surgeon'~ notc \tates that the patient \\,t~ reportlOg good progre ... ~. Elbcm tlc\lon ROf\1 \.. 3...... now 20 to 110 . The patient continued to have 0" of SUpll1atlon wilh 90 of pronation. The pati~nt atlhb tllnt: abo reported lIO complain" of pain but was no\\ fl.'pOrtlO£: pare\lhesl'b 10 the ulnar nerve di~tribul1on Mu~le lunCllon \\a\ reported JS hClI1g Intact.
312
Physical Rehabilitation
Table 9.1 NCV Results: Median Nerve Wrist
4.0 msec
4.2 mV
Elbow
7.2 msec
4.2 mV
Sensory II
2.4 msec
Sensory III
2.4 msec
A follow-up visit had the patient reporting weakness in her hand and atrophy was noted in the ulnar intrinsic muscle. The patient had persistent numbness and a referral was made for electrophysiologic testing. A brief clinical examination done prior to the eleclrophysiologic testing revealed numbness in the uJnar nerve distribution. The patient had weakness in the ulnar nerve distribution and manual muscle testing of the first dorsal interosseous was 015, abductor digiti minimi 015, flexor digitorurn profundus to the fifth digit was 2-/5, and the flexor carpi ulnaris was graded as 2-/5. Atrophy of the intrinsic muscles of the hand was obvious. The patient had a positive Tinel sign over the ulnar nerve at the elbow proximal [Q the cubital tunnel. ROM for elbow flexion was limited to 20 to 110°. Supination was 0, pronation was 0 to 90 degrees. The patient also had marked reduction in shoul· der motion and abduction and flexion were 0 to 60°. Wrist extension was 0°.
TEST RESULTS Tables 9.1 and 9.2 show the results of the nerve conduction velociry testing of the median and ulnar nerves. The right median nerve showed a borderline nonnal distal mOlor latency, nonnal distal sensory latencies, nonnal amplitudes of motor and sen~ory responses and nomlal conduction velocity. Examination of the right ulnar nerve presented difficulties becau~ no response was obtained in the recording from {he first dorsal interosseous or the abductor digiti minimi when ~til11ulating the ulnar nerve at the wrist and elbow. Also 110 sensory response could he obtained in the hand in {he ulnar nerve distnbulion. The ulnar nerve
63 m/sec
study was done by recording from the flexor digitorum profundus (ulnar nerve portion) by stimulating the ulnar nerve above and below the elbow. This revealed a very small amplitude response with a normal condition velocity across the elbow of 60 mlsec. Increasing the length of the segment examined across the elbow by stimulating in the upper arm and below the elbow revealed a conductioo velocity of 50 m/sec. The molor response recorded was markedly reduced in amplitude and the waveform was dispe=d. Recordings were made using needle electrodes. An EMG examination was also performed. Table 9.3 summarizes the results of this examination. EMG findings in the abductor pollicis brevis were nonnal. No activity could be recorded in the first dorsal interosseous. In the abductor digiti minimi the patient showed a few highly polyphasic potentials that were of low amptitude. In the flexor digitorum profundus (ulnar portion), the patient was able to generate polyphasic potentials that were both large and small. The interference pattern was never beller than one third of normal. The recruiunent of mOlor units was a problem. The tlexor carpi ulnaris also revealed polyphasic potentials that were large and small. Recruitment was incomplete and the interference pattern was never better than 1/3 of normal. There was no signifi· cant amount of spontaneous activity found in any of the ulnar innervated muscle~ on this examination.
GUIDING QUESTIONS I. Ba~ed on a review of the eleclIophysiological exami. nation rcsults. characterile the function of the median and ulnar nervcs. 2. \Vhat i~ the possible cause?
Table 9.2 NCV Results: Ulnar Nerve
I:~~~ow ~
3 9_ msec _ _ _ _ _ __
AlE/bow 60 . msec UlArm 7.1 msec Comments' Needle recordIng from FOP(Vj
200 ",V 155 .. V ~
150
6 mlsec
V '"
[50 m/sec)
wa'vetorm-dl::==------:::::.~=:::.--- ISpersed.
-
Chapter 9 Ht."(,lrom)oK~phy and. ene (onduclion \t~locily Tesl.l(
APB
0
NMU
Normal
lsI DI
0
0
0
0
Small polys
Marked decrease
0
Polys-large and small
1/3 N
0
As above
1/3 N
ADM
--FOP (ulnar)
----
FeU
----
J tJ
----- --
ADM ::: abductor d'9ltl minlmi; APB z abductor pollds brevIs; FeU ::: flexor carpi ulnaos; FOp::: flexor dtgitorum profundus' 1st 01 ::: first dorsal interosseous.
References
~
6
7.
S 9
10
II
Green. RM. Commentary on lhe Effect of Electricity on Musculllr Motion. Elizllbelh Licht. Cambridge. 1953. Medved_ V: M~J"uremen' of Human Locomotion. eRC Pres.,. Boca Ralon. FL. 100 I Geckk.... LA. and BJl.er. LE: Pnnclpal~ 01 Applit"d Biomedical ln~lTUmentation John Wllev & Sons. e.... York. 1968. BI.llc Medillnc Mu'>Cle & Nene 22 Suppl 8. 1999. 59. Trojabofg. W .MOIor !len'e l,;onductton \eIOCHle:> III nonnal ,ub)CCU ..... lIh p:lrtlcular n:Jerenl:e 10 the condul'lion III pro,Cgmet1l~ of me(han .lI1d ulnar nenes. EleclToeocephal~r ehn NeurophY~101 l7:lI-~ 1~ 60 [}d~)on. GD. 1be relali~~ ell.tllabililY and conduction wloclty 01 sen!lOf)' alld motor nc:nc fibeT'> III man J Ph)slol (Land) I] 1'~16 1956 • 61. Hoflman. P Uber die bellchungen d, r '\ehnen rene\c 7ur '.nlkurhchc:n ~egung und lum lonus. Z BioI6b::J51. 191M 62 C.M:f'h. MR ElcctfOlherar) 1II RchabllilallOiI. FA D;t\"I'> PhlIoidelphl3, 1992 . 6:\ Sat>bahl. MA. and Khalil, M Se~llIenlal H-retle\ 'ludle!> III up~r ,I.lld lov.er 11mb of Ilealth) ~UbJl:d\_ An.h Phy.lo MOmebic , BaltiOlllTe. IQ80. QO. ...r am. Gp· ReltaMlt) of eltttlOm)ogrdpbll me~uremrDI:iI'" \u, Ia..:e t'!rctrudc Ie I ~Q:JI5. IQ7'J mO\a an.,1 repl.M:c.'lIIent Pcn.ocpl Mot SUlk 91
Y~n1!. J~. Jnd' \\Intc.'r .Ok EIa: 1ll;,1 and ub . . . ·lromyog.rJph) reliabllily If) IDIlU'" 1ll..l\m1aII~Ill\;"ln..: l:OOtri t A 'h Ph Pdtd Rehabll fl..!'-117. 1910. ill J()/h. rc )l>
Ck ",,"uvll:y e-r Onll:lJll e 01 .lourfa,-·ular \loIre elet:trodes .. ,piIi Y V·: lOp e, .'. 'bOo I Q~5 1. ma,alu. JII .md Kon' PV S· !Urelll(nlS. Acta I'II)'IiI&
or
Chapler 9 Electromyography and Nerve Conduction Velocity Tests ~ Winter, DA: Thc 8l('1lllcc hanic~ and Mmor Control of Walking, cd 2. ~m\cT"\lI) of Wtllcr!I)O Pre:.~. W:ncrloo, C:madll. 1991 . Q5. Kelt,:., E: Tht' effct't, of frllig.ut" on the re~uIt3.nI Joi nt 1~' ~l1lenl. :lgoni!hJp~ in human muscle~. Am J Phys Med RehabLI 6'2:287.1()83. 107. Vredenbregt . J. and Rau, G: Surface electromyography in relation 10 force. mu",1e length and endurance. In LRsmedl. JE (ed): New Devclopment~ in Eleclromyography and Clinical Nl:uroph~sl1)log.y. Vol I. Karger. Ba~L 1973. p 606. 108. Zumga. EN. and SnTIons. 00: Nonlinear rdalionship Ix-tween .l\era~ed electromyogram 1"lOienual and mu~cI(' t e n ~io n 11\ nonnal SUOJcCf,. An:h Ph\" ~1ed Rch:lbI150:613. 1983. 109 LaIHence, H-I . and IA:Luca. 0 . tlilyoelectric )'ignal \),. force rela~ lIonshlp Ln different human mu),c!es. J Appl Ph y~io l 54: 1653. 1983. 110. Bigland. B. and Lippold , Oel. The rc1:uion bt:lween force, ve locIty:md integrated e1e~-tncal actl\1Iy in human mu~de~ J Physiol {Lond) 1'23-214. Iq54. III Pe'lJof~l.y. JS. et al: E\ :;Iuallon of Ihe amplitude and frequency eomp..lneil!;; of flIt' ~urface EMG as an mde). 0 1 mu~ck fa tigue. ErgonomIc'; !5:~ 13, 1982. 112 DeLuca. CJ: !v1yoeJeClnt:1J m:mlie~tatiom, of local1Zl!d musc ular t.l1J!!UC III hUlllt:lm. C ril Rev B IOllled Eng 11 :25 I . 19H5, III Kuonnka, I. Rt'~1 1IU\l(m of EMG spectrum after Inul>cular f;wl!.ue. EurJAppIPh~"uI57.3i1.19!:18. 114 HLliJIIII!. PA, ('I IIi: Tr1cc:p' ....ourcc EMG 'JXclrum changes durms ~U~l
146. Kankaanpaa. M. el 31: Back and hlp C1L:lenwr (:ltJgabalu)' 10 chronic low back p:lln patienb and
('(lntrol~
Arch Phys t\1ed
Rehabil 79:4 12. 1998. 147. Mannion, AF. el al: TIle use of surface EMG power ...pcctral :103Iysis in the ('valuation of back mu-.cle funclion. J Rchabil R('" Dc\' >4:427.1997. 148. Ro). SH. elal: Lumbar mu-.cle f311gue and chromc lo"cr bad pam. SplIle 1.:1:992. IQ89 149. Moone). V. el a1: Relalion bet.... een myoeleclnc 3Cll\.1I). strenglh. and MRI of lumbar e\:lenthcr mOlar neuron dl\Qfders \1u:-l.le \.~ne :!Jl WI" 1':"1.;, .:'t1Ull Ib~hlgill. SS. B.tra.pend. Equipment u,ed in a gait analY~ls may be either a:-. :-.imple a~ a penc il. paper. :md stOp,"·atch.::4 or as complex a\.m electronic imaging "'y~tem \\ ith lorce plal e~ embedded m Ihe noor.~"~() To :-.elect Ihe "IPpropnme method. the Iherapi ..,t l11u t Unda\land~ the gail dUr:.1Llen'Iu.:.., ' )1'11.: ..11 ,,' ... p.o1/1':u br dl'1order. th~ nlt:(h~ul1!'.I1l.'1 Ihal Jft" u. . lI.lll) re"'pon\ lble. and Ihe t:Hcl lI\ene:-. . . of ... ppropmttt' mlef\ t'll llon .... ' lI11pkr galt Il·fX.J.h.:d
1( .. I IIl~ \\lIhll1 Ih\.
10 ulllhnll ,l'Ila h d,l\
The Gait Cycle
Phases of Gait T r;1d ll llln.lil ~
l·.1I.· h rh ..ht' 01 gJ.lt \ ... I.Ull.·t." .md ... \\lIlgl h3, he('n dl\ II.k d Into Ihe h lll o\\ I1lf Ulll'" ... 1;.1Il\.'('" \heel ~rn ~ e . 1 ~"W")ln"lI . I1\ IJ'l,tJl\.\.' hl'l"I -ott. ,lIlJ (( Il·'I.lft I .U1d ,\\ IIlg l acl'e!l'TJ ll ull. Il lllh\\ Ill ~. .J.n d dl~ ""t' kr.1l10 n I . TIll." Lo ... ...\ mlg,"l~ R l~ ...c..u\·h and 1 JU\J.!lt1n In ... lltUle . In\.' Iridl:. RIg ht '> Imk le ng th i, Ih.: dl'>t.uKc h!:t .... eeJ1 Ihe POUli 0 1 ('Ontact of Ihe righ t hed (,I[ tho.: 10\>0':1' kit comer 01 Ihe dl;.lgram) and the nl'>.t (t)lllad 0 1 the n ght hc!;'1 Lelt ,tnde I c n~lh i\ Iht." di '> 1ancl' he !\\ee n thl' point 01 1..'011ta('1 01 th ..: lett he"' ] (al the IUp le lt 0 1 thl' t.1l .. g ram l 10 the puinl 0 1 Ihe 1ll'>. 1 It'll heel. f ,l("h ,>Irlde l'oJl( il in\ t wo ... tc p,> , bUI 0111 ) bllth ... h'p:-. Hllhe letl ~ Indl' . If lilt" (li q;.lllll' nd\\t'l'll lhl' Ildl lwd lUlltdlllo Ihe pO lilt 0 1 till' rlghl hl:.1 kll ht'l:! Lon l,,(1 "' ll-'p ,uld .. Iride IInlC''> rd..:r to Ihl' ,UIlC)unt 01 lime Il'ljUII.:J 10 C(unpkte;l ,>lep ;.lilt! I ~I (Om pielt' ~ Ind l', le ~ l)el ll\.:l )
COll1dL! :It
sis is used to detennine the forces invo lved in gait. In some instances, both kinematic and kinetic gait variables may be examined in one analysis. ]n addi ti on (0 examining kinemati c and kinetic variables. physiological variables such as heart rate , oxygen consumption, and energy cost may be considered,
Kinematic Qualitative Gait Analysis The most common method used in clinical settings is a qllalitarive gaiT analysis . This method usually requires only a sma ll amount of equipment and a minimal amount of time. The primary variab le exam ined in a qualitative kinematic analysi s is displacement, which includes a descripti on of patterns of movement. deviations from nomlal body postu res, and joint angles at specific points in the gai t cycle.
Observational Gait Analysis (OGA) The Ral1cho Los Amigos Obserl'mional Gait Analysis (OCA ) system is probabl y the most common OGA system
used by ph ys icallherap ists.:!9.JOPodi atri sts have developed th eir own unique OG A system .JI The Rancho Los Amigos OGA method involves a sys tem atic ex amination of the move ment pattern s o f the fo ll ow ing body segments at each point in th e gail cycle: an kl e. foot, knee. hip, pelvi s, and trunk . The system uses a reco rct ino fo nn comprisin 0o 48 ~ desc ri ptors of C0111mon ga it dev iations such as toe drag, ex(.;essive plan tarll exio n and dors itl ex.ion , excess ive y arUS or va lgu s at the knee or foot. hip hiking, and tr unk tlexion. The o bse rvi ng therapist mUst dete nn ine whether or not a deviation i ~ presen t and note the occurre nce :md timing of the ciev iat iun on Ihe ~ pec iat form . \L1 Co n ~ iderab l e training and p r1 Imperial Highway. Downey. CA 90242 . A bi omechamcal gai t analys is fOlm for podiatri st'), de\cribed hy Southe rland .'1 i" pre~ell1ed in Fi gure 10.4. Thi ~ lorm i. . lI"ed In conjunction with a ~t a t ic quanti tati ve anal y~ i . . whIch incl ude,) m ea~ ure rne n 1:-. of range of moti on (ROM) oj a ll J ()rn ( ~ from Ihe hi p 10 the tOt~"", a:-, we ll ill> m~a" u rerntll\ " of limb length. De ta il ed infnrmal io n i ~ a lso tolletted (Ill bot h the dor~a l and plantar ~ urrace " 01 the fee t !o,Udl a ... (allu ~ Jo nnall OIl .mJ curn ~ . The examine r I ~ expeckd 10 duioll. )
undep,tand the normal roles and fu ncti ons o f muscles during gail and the nomlal forces involved. 26.29 .38 Dev iations from normal occ ur because of an inabili ty to perfoml the tasks of walking in a nonnal fashion. For example. a patient with paral) :-.IS of the dorsiOexors (which causes a foo t drop) cannot arram the nonnal neutral position of the ankle necessary to complete the task of clearing the floor durin g the swi ng pha\e. Therefore. the patient must find so me other method of clearing the floor. The patjent could co mpensate fo r the mabilit) to dorsiflex the ankle by some method such as increa!'>ing the 3mounl of hip and knee flexio n above the normal amount, by circ umduction of the ent ire lim b. or by hi kmg the hip. The type of compensation that a particular indi\ IduJ.1 \elects depends on the specific di sability. Increased hip and \...nee flexion may be used if the patient has an isohued problem in the ankle and adequate muscle strength and ROM III the extremit y. C ircumduction or hip hiking may be u anlle and fOOl l '!et lmm ) ()!-'I "'phil ( [ \ lei) rl.'l'llrLllllg' IllJ) :-.hO\\o p.NI,)n~cd .Idi\ 11)' In tlil' lIU,tdricl..'p'" and II1lh~ dur-
I he F}~ I and fram ing 10 d llll ilutt ng bias \.. ould improH~ ,let'ural') .J"
HI}.: Inpi.llll!nt n:iJ functions of Ih .... pI.lpU lal hlll'> oJ uu!tvitiuJI ... \\ ho .)lhlajnt"d traumatic hl.UII IIqUI\ ( 181l a llJ \tro ~1;·. rl· ... ,)c-', IIldqxndencc 111 amhllialulil For n~UllpIL' ... p..tllult mil) need LO allain .. ce rtain £JIt ... peed in l·rn ... ~ J \(K.ul . . Ire..:{ '" IIhlllthe lime alloll co hy J Lw' . . mg II~ht, or a )l a l l~llt may Ilt!eli 10 walJ.. t)Ut J P("nl he ight and we lghl, .. Jevel of • " • ' I "cti vit y' (..1.6" and level 01 maturation. attempts pIlY,lCa... haw bee n rlli.ldc to lake some of t.h ~~e fac t or~ into. aCCOUnl. Ratios, MICh as ~ Iridc- Ic n g th diV ided by fun cllonal LE lc ngt h, ma y he used 10 l1orT11a l i~~ for differenc~s in palient:o.· leg length". S tep len gth diVided b~ the, subject's he ight ma y be used in an attempt to nomla il ze differences amon o pati el1l!\ ' he ights. In an allcmpt to control for bolh h t:i1!h~ and we ight. body we ight is divided by standing he i ~ hl 10 yie ld Ihe bod y masS index (BMI) . Olher ralios arc ~I sed to 0 I..tll hl' d~lt.:nnlOed ,impl) .Uld IlIe\llen~i\'eJ) b) / C'l"ll] .llll~ thl.' P,II 11.'111 , It It Ilpl Ill!.., during gai l. S IIIlpJe mt!lh . )(.I. . III 1~>1. III dlEl ~ l.h11Ilnlll . . Inl.· l\ld~' Clthl!f Ihe" application of p.lll1h InJ.., or d\.\I~ 10 lhl' hOllom of th...' pi.lli ent 'S fOOl or . . hOi..· UI Ihl.' ,m.,dlnh'nt ut inh~u paih or o ther marker.,. Ftll' .;\.IFnpk .I kit lIPlk~d fIl.tfJ..\.!r IllU) ~ taped 10 thc bad of ,I P.. lIl· lIl ..... ,ht~' l i'l lIg th!:".: l1It"thud" ll1ea.:,urCU1enl~ of
Chapter 10 Examination of Gait
339
Table 10.19 Gait Variables: Quanti tative Gait An alysis
11 ; 'h
~.
•
• •
"
• 1. .. '''' ' .... ,'
...
• •
• I ...
Speed Free speed Slow speed Fast speed
A scalar quantity that has magnitude but not direction. A person's normal walking speed . A speed slower than a person's normal speed. A rate faster than normal.
Cadence
The number of steps taken by a patient per unit of time . Cadence may be measured in centimeters as the number of steps per second Cadence =
number of steps time
A simple method of measuring cadence is by counting the number of steps taken by the patient in a given amount of time. The only equipment necessary is a stopwatch, paper. and pencil. A measure of a body's motion in a given direction. The rate at which a body moves in a straight line. The rate of motion in rotation of a body segment around an axis. The rate of linear forward motion of the body. This is measured in either centimeters per second or meters per minute. To obtain a person's walking velocity , divide the distance traversed by the time required to complete the distance.
Velocity linear velocity Angular velocity Walking velocity
distance time
Walking velocily =
Walking velocity may be affected by age. level of maturation. height. sex. type of footwear. and weight. Also . velocity may affect cadence, step, stride length, and foot angle as well as other gait variables. The rate of change of velocity with respect to time . Body acceleration has been defined by Smidt and Mommens2 as the rate of change of velocity of a point posterior to the sacrum. Acceleration is usually measured in meters per second per second (m/s2). The rate of change of the angular velocity of a body with respect to time . Angular acceler· ation is usually measured in radians per second per second (radians/s2).
Acceleration
Angu lar accele ration
The amount of time that elapses during one stride: that is. from one foot contact (heel strike if possible) until the next contact of the same foot (heel strike). Both stride times should be measured. Measurement is usually in seconds.
Stride time
-
Step time
The amount of time that elapses between consecutive right and left foot contacts (heel st rikes) . Both right and left step times should be measured. Measurement is in seconds.
Stride length
The linear distance between two successive paints of contact of the same foot. It is measured In centimeters or meters. The average stnde length for normal adult males is 1.46 meters. The average stride length for adult females is 1.28 meters.
SWing lime
-Double support time
The amount of time during the gait cycle that one foot IS off the ground. Swing time should be measured sepa rately for right and left extremities. Measurement is in seconds. The amount of time spe nt In the gait cycle when both lower extremities are in contact with the supporting surface. Measured in seconds.
--
I Cycle time (str ide time) -
Step length
-----
---
The linear distance between two successive pOints of contact of the right and left lower extremities Usually a measurement is taken from the pOint of heel contact at heel strike of one extremity to the pOint of heel contact of the opposite extremity. If a patient does not have a heel stnke on one or both Si des, the measurement can be taken from the heads of the first metatarsals. Measured In centimeters or meters.
-I
-
The amount of time required to complete a gait cycle . Measured in seconds.
------ - - -
-
Width of walki ng base (step width)
The Width of the walking base (base of su pport) IS the linear distance between one foot and the Opposite foot. Measured In cen timeters or meters 7
Foot angle (de gree 01 toe out or toe In )
The angle of foot placement with respect to the hne of progression. Measured in degrees. 7
-
--
-
-
-
----
(continued)
3-10
Physical Rehabilitation
Table 10.19 Gait Variables: Quantitative Gait Analysis
~
(
The \ 'icon MIJllon Analy'::>i'i S, ~Ie m® is also able to incorpurah: ~ 1!lC'l h: Jat,\. Th . . . Vi~()~ Data S tallo n ::,ynchronizes "Ignal .. from the Viclln came-rilS , and proVides fo r d tItct IIlteg r~tl l on of dala trolll de\ 11.:('" :,uI. h as for~e plates and
f-M G 'I~slt~m~
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>ina!) "'1:- ") "ll'm pmdun~J b~
~\OIH' aJld IHurl" lnumali\L' 1llt'l h\\i..I, 01 qu,IlIlJt~ \10 dll~ I..ft'JleJ Hovvl;'\t:1. 11ll' mO"'1 1ll1pOrUot ..... \Ul· tnl 1I.:1 1<Jbli1l..tlIt111 prolL""Hmah j, hO\\ rl'll.lbk ,Int! \.tlid tilt' Ilit01l1\.I111111 1". and IHI .... lnlollll.H IOIl l all he: III1U.: 10 1Jl1!;
hunl.lfl :g.tll
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·r.hcd III Ihl (IUIJ. t l.J.hl (' 11.121 JnJ IO~.:' plt"cnl luJln Iliu'lr.llillg h(h\ tllf C:11 111 1)111111 Jnitl\"'I~ .. , ... 1("111 ...Ire tx:IJI~ ll,\"~l h\ Il$.(" .... hl-r III, t.1bJ Inlludl" fhl' porpo ...... vi Ihl· 'fUJ\ dl'
)1It~on .jJI..tl~ I ~\ h"llIlh\.'d \...tflJII(::... Ilh.' ".Jfl'J .IIIJ h:l \ .11l! I !lotllt
Jlh.tIlI"!'I:, olllllll ~1H~i dl'l.lHH· nit·..! till' .. ill' lktl'IlUIII.d ... lIlIpl\ J.IJ In\."jX'fI"'I\~I\ Iltd ) tcld ubld: 11\ ".•UIJ tdl':lhh: h,I",ltn~ d.II.! 1ft. t
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lX' u'cd to Il)rmu1.1.l\,.' ~ntll' l patc;"d goal,> and ~'(pec!ed
Oll s \\ Ilh
Gait Pattent C lassification Idt:lltlliLdt lon 01 g~tJf paramdth Iha l dt!V ldlt' wide I) Irllm ~ norm i\ urface. The force i... Ihn.:e-di111l"lhlon .. ! and l:all be re~o l ved into threc componCIll,). \~rt l (:a l , alllt: rJ{J ]'- postc rH)f. and nlt!dial - Ialt! ral. .E:.ulh cOll1lxment va n e') thro ughout the gall l:Yclc a nd i ~ :Jlh:cted b) vclouty. LaUe nl.:c. and holly ma ~~. The ave ragtd Wave lorm~ 0 1 the vC '1icaJ anci an t en o r-po~ tcnor lORe lOlllrUllt' Ilt ~. prc;~e Oled a:-. a pe rcentage of bod y
Force plate tech no logy, suc h as that produced by both Ki stl e r Instrum ent Co rporati on a nd Advanced MechanicaJ Technology. Inc (AMTI ). is capable of measuri ng the ground re,lction force (GRF) as we ll as calculating the Co M. accelera tion. velucity. displacemelll. po wer. and a·ork. A grap hi c di splay is possibl e showing the wave fo rms o f rhe GRF. Ki stle r InMrume nt Co rp also markets a treadmi ll ca ll ed the Gait way. The treadm ill is capable of m e a ~ uring the GRF and CoP during bo th walking a nd running. In additi on 10 graphi ca l presentati on and stali:.ticnl fun cti ons. the tread mill ~y ~ l e l11 ca n calc ula te km poral !'lnd spati.ll p a ra m e t e r~.
Cook ct al " used a force plate to investi g,lI e the effec t o f a knee Il ex ion re ~ l r iL: li on (us ing a bran!) and wa lking 1'> peed on the G RF. T he authors concl uded Ihal the ~lpph c a !Ion of a brace 10 re~ tfl c t knee Il c"ioll for the purpo, e o f prolcl,tion ;:t h e r injury, or whil e ~ lI rgic al l y re paired Mructu re!-. were hea ling. lll ay ac tuall y in L: re a~e thl' ,, (r~ss 011 ho th the braced a nd un bntt ed limb ... I-Ie ......\! d al5 l'omp;m: d the traj l."cturie'i of the CoP and tht' CoM in 10 hC;.l lrhy and 14 suhjccls wil h hem ipares is.
.154
Phy~icaJ
Rehabilitation
TIley found that the health y ~ubjcct" ,ho\\ ed no d ifferences in the be ha\ ior of the Col'. CoM. temporal parameter'l. and step length \\ hen initiating gait with e ither the righ.1 or Ic~'{ eXlremi l) . In comparison . pati ent ' with helmpare ... ls ~h owed pron ounced asymmet ri c behavior dependi ng on \\ hich hmb wa.;; the startin g limb (affected V5. nonaffecled). Whil e pali e nt~ who initiated gait with the affected limh were similar to health y ... ubject ~. patient' who started o ail \" ilh the nonaffected limb showed incon ~i st ent movc~el1t of the Co P and \\ ere in ca p(\bk of produ cing direc· tional Illo\ emcnt of the bod)', CoM . Therefore, therapi sts "houl d be ca utioned about promoting that type of gait initi o ation becau ::.e the affected leg ma y be too weak to suppo rt slart i n ~ Iwit "dlh the unaffected leg. Ross i et aJ1 inve~ti gated ;h; CoM , Co P, and GRF in a study of gait initiation in patients with t ran ~t ibial amputation:--. Th e~e authors found that the palienb consistentl y loaded the intact limb morc th,:m th e prostheti c limb regardle~s of which limb initiated gai t.'" Force plate ... may be used either 3!-. pan of. or in combi · nati on with. motion a n a l ys i ~ .'))'.') te01 '\, and may be used with temporal-distance .ma l y~is ~) :-,tem'\. as well as in con· j unction wi th EMG and elec trogoniometry. for a comprehensi\ e anal ysi~ of kmemati c and kinetic gail v ariabl e~.
Plantar Pressure Measurement Systems PreS5ure meawrement sy~te l1l s rn a) al :-.o be used \\. nh force plate.'). Press ure i:-, eq ual to force di vided by area and I.') measured b) pre . . :-. ure .. e n ~o r~. Therefore. pre,suft: \s equa l to the fo rce on the se n ~o r di vided by the area of the sen .. or. PI.lIltar pressure mea\uremenlS are mo~t L'ommonly in gall anal) .. IS LO delerm llle the pres~lIre distribu tion unde r the foo t: foot-to·ground contac t. foot- to· ... hoe contact. .md ... hoe-LO-ground c:onLdL't. Pn........ ure mea~ u re m e n h n1.\\ he u.,ed ttl delenm ne orthotk e llic;Jcy. ukeration fI'I l-.. III lh:.tbe l e~. and for regu lating we igh t beann~ fo ll owing "u rgery. ~h ny d i ffe r~nt t) pc ... of mCJ ... urcment tethn iquc ... ha\ e het.:n de\t~loped 101 m ea ... urlllg t:OnlaU pres" lIre~, Td. sc~1I1 Inc ( 8 0"'1011 \'1 A ((! 127) ha ... a \) . . tcm called IhL I ·Sum" Bipedal Ill-Shm· IJlul/lar P /(',\.\l/rt' Font· l l l'IHIlI!'nIl'JIl S),HU !' th ai ll1 L"a5U I~'" bIpeda l pl.mtar P'(',\ ... UI t":-. 1I"'1J)~ Pdpt!' Ihm dl"'po"ab l ~ prc... ... urc "'eINH~ plm.:cd III i.l path,:nl ... ..,hoc!'!. Th ~ :..t:n"'Or I ' ulilJlllIn. lin Ib ll' and II IIllrnahh; v. IIh %0 ...t n.,lIIg 1{)~: .... tIOIl'\ J I''IlnoulcJ Jl..ro~ ... lht: rn ll n.' plant,lI wr1a(~ All c\Jmplc 01 lhl' t), l~ lit IlltonniJlIOn "h l .lln~d 1"'111 tilt' F· ...lan ,,:Mem " P I l''''Clllcd 111 h ~ull' 101". Rt'Ii;.,hd it) 01 the I "'I.. u j mle rycntlon~ ... ueh a'\ the lI:,e uf llnllO..e, Ph\ .lu1,!H..aJ L\)\t .lIleIlL IIR me ..hure\ h,J\t' ~ell ..,howl1 10 Ix adequ .56); for one-foot standing, reliability highest in mediolateral direction (ICC = .84) ; reliability of walking tests ICC values ranged from .79 to .94.
Triaxial accelerometer
6 men, 14 women (mean age = 35.2; range 18-57)
Measurement error values were very low (0.007-0.01 for mean acceleration to 1.644 step/min for cadences). Reliability was high with ICC values ranging from .77 to .96.
Gyroscopes
Data from a uniaxial gyroscope (ENC-05EA, Murata , Japan) was compared with simultaneous data produced from the Vicon Motion Analysis System. 2 pairs of force sensing resistors placed under the feet of 9 young (mean age = 21 years) and 11 elderly subjects (mean age = 79 years)
Good correlations we re found between the signals from the motion analysis system and the gyroscope.
Gyroscopes
New algorithm based upon wavelet transformation to detect toe-off and heelstrike from angular velocity
Good agreement (f > 0.99) was found between actual gait events detected by foot sensors and events detected by gyroscopes. No significant differences were noted between sensors and gyroscope for gait cycle and stance times, stride length, and velocity.
GAITMAT II
5 rate rs determined the
GAITRite
GAITRite system compared to paper and pencil recordings and video
GAITRite
Relationship between the FAP, type of stroke, patient's functional disability, and spatial and temporal variables. Compared footprint parameters to the FAP In 62 healthy subjects
1999
Aminian, K et aj134
2004
Pomeroy, VM , et al 77
2004 Bliney, B . MOrriS , M, Webster, Kl 3S
2003 MCDonough , AL et aP36
8 of the 17 parameters tested showed spatiotemporal parameters Significant differences between raters. of 19 stroke patients -----------------~-----------------------------GAITRite and 25 healthy adults walking Strong concurrent validity and Stnde Analyzer at fast and slow speeds test-retest reliability, but best at preferred and fast speeds.
2001 Titlanova , AEB and Tarka , IM n7
1995
(continu •..!)
SAM
1999
Moe.Nilssen, Rn
357
---
------
High correlation between measures of cadence, walking speed, right and le~ step and stride lengths, and step times.
Found GAITRite easy to use, suitable for repetitive measurements and quick to report information on temporal , spatial, and footprint parameters,
(continued)
358
Physical Rehabilitation
· Exammmg .." . Methods of Gait Analysis Table 1025 Salient Features ofStud.es .anous
Nelson. AJ . et al'"
GAITAite
People with early stage Parkinson 's disease and healthy controls at preferred speed. but not at fast speed
Discriminated between groups patient group attained a significantly lower FAP score). ICCs for all variables were 0.92 and higher. except base of support (ICC ~ 0 .80). At fast walking speed all va riables had ICCs of 0.91 or higher, except swing and single support time (ICC ~ 0.89) and base of support (ICC ~ 0.79) .
GAITAite
2 1 healthy subjects (19-59 years)
At preferred walking speed, ICCs for all va riables were 0 .92 and higher except base of support (ICC 0.80). At I fast walking speed, all variables had ICCs above 0.89 except base of support (ICC 0.79).
2002
Van Uden , CJT, and Besser, MP l39
(contiftuod)
=
2004
=
Menz , HB, et al'4()
GAITAile
30 healthy young people (22-40 years) and 31 older people (76-87 years)
Test retest reliability for both groups for w alking speed, cadence, and step length we re excellent (ICC between 0.82 and 0.92 and coefficients of variation (CVs) between 1.4% and 3.5%). Base of support and toe in/out angles had high ICCs, but were associated wilh higher CVs (8.3%- 17.7%) in young people and 14.3%-33% in older subjects.
Ariel Performance System
Skeleton with 9 passive markers placed on the pelvis and lett LE. Joint angles were measured with an electronic inclinometer.
For most trials, the APAS and GaitLab™ hip and knee flexion and extension angle measurements agreed with the inclinometer, but occasionally large nonsystematic disagreements of up to 18.6' occurred. The only consistent error was with hip abduction and adduction using the APAS sottware (32-97'). Not unexpected, because the system calculates angles using marker-to·marker vectors and no marker can be placed on the actual center of the hip joint.
Anel Performance System
Reconstructed angular estimates of the Ariel Performance System
Mean errors were consistently within the range of + or - 1'>.
2004
Besser, M, et aP4 1
1996
! Wilson , OJ , at ap.4 1997
L __
2
--- -_._---_.-
EFAP -"'" Emory Functional Ambulalion Profile; FAM :::; Functionat Assessment Measure; FAP ...; Functiona l Ambulatlon Proftie ; FEMBAF ;; Fast Evaluation of Mobility, Balance , and Fear; FIM :::; Functional Independence Measure; FIM T FAM :::; Functional Independence Measure (FIM) plus the Functional Assessment Measure (FAM) ; GARS·M :o;z Modified Gait Abnormality Rating Scale; ICC z::. Intraclass Correlation CoeffiCient; MEFAP ..,. Modified Emory Functional Ambulatlon Profrle; SAM ::.. Step Actrvlty Mollltor
oxygen con-. umpl ion wa\ 32 pen'enl greater Ihan normal and Ihal I-IR wa~ ~ igniti c~J1Ily grea ter than nonnal.l~17 An energy index ba ...cd on I-IR tailed the Ph)~iolo.r:11 til Cost IlIdl'.l (PCI) wa~ developed ~pec ilically 10 dt!lernllne the relative CO~h 0 1 v.a lking per unit uf di~tance walked , llll Caku lated a... the diffaence belween th e wa ll-..tng IIR and
the reO:; lin g HR dlvldeu by the average speed, it is (:·x pre~"'I!J. in beab
per IlWler. Some re\t"archt·r~ have found oxygen uptake me3SlJl1'i to he more repcat.lble and le~~ variable than pcI. 1I7- 119 In _ ~I udy. O'\)gen C05.1 w~ found to be considernbly more reJi-
J bl C
I h ~Hl
Dr>
n ,.
I.
. Uldll: ..ulng 1)OmeWhal low
..' "' PCI senslUVtIY-
C hapter 10 Examination of Gait !jzen11 a n and Ncne l10 c?ncluded Ih~1 subtracting baseline heart rate when calculatmg the PCI IS probably not useful bccau ,e it increa., ed within -s ubject variability. It is possible fhat thl' PCI has bette r repeatabilit y with unimpaircd subje
,C- \1\O.ltYJI l.l Self. BP_Gfl'Cnv.ald. R, and Pfiaster. DS : A biomechantcal anal ),'I~ of medial unloJdmg brace for o')teoanhri lls in the knee. Anhnt Care Rc-, 1;\- !IJI 2000 15, GOI... H. el J.! Eftecb of unkle-loot o nhoses on hemiparetic gail. (1m Rehab 1- I ~7. ~()O'16 \\nue. H. el al Chl1lc~JJ~ pretrate an mCft'a'>l" in Ihe \'elOClt~ ()f gall 111 chi ldren v.llh cerebra! pal s~: A retro~pe...:tl\c- 'llJ(h. [X\ \1ed Chtld Neurol-l.-l.:227. 2002 . p . . kCulhx:h \1 JI: The effect of foo t o rthotics and gall ve loc ity on lo\>.er limb I..mcmJ.nc~ and tempoI"'..!1 e\enh . J Orthop Sporn.
!"I
Ph~" Thcr 17_2 !If./~ P" Eng. JJ, :md Plemr. ,..... oJ:1. 'v1R : The effect 01 !.Oft fom o rthoticl> o n
three-dlmen~lon..tJ k,· ·lr IHnb kinematlc.l> and ,,-metic!> dUn n2 v. alk-
mg....nd running Ph~ \ Ther 74 :836. 1994.
~ 19 R adk;l, SA_ el ..II _--\ ~(·mrJn..on of gall v. ith !>olld. d) 1l11llllC and no Jnlle-iool OI1ho'-t', III .::hdJ ren .... nll 'p:t~lIC cerebral PJI~) . Ph }~ Tller .,."W)_ I'N~ 2fl Gri1fl;l\a. KP l,bd \If', Jnd Daml.1no. DL: J011l1 anj:!u lar \dOC i t~ In 'P~~I I( gan MI J lhe IIlt1Ul:nL e uf mu ..... Ie-lcndnu kngtheninc . J
'I
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J.i
L11e..h
-
u! ytJwnceP'> musclt: ~trengthening
01)
~P,",-,Ul lfJPlcgJa P h), ·n}{'r 75 :tl58 . 1995. s.,11fI SlItei1l1ngt'n J\1. ~t .11: Th~' M(xillil.'d G,ut Abnomlah l) Rallng d ;tIc tur R;u'gnll1:,~ UI~ oi re~~urrent fall ') to ..:ommunlt).... elJmj! clderl. ".:lull) Ph)~ nt"'r 76:994 . l\jl)tj Sl!um ......r)"( L>I ."... _.... _ 1.'1 dI PrC-du:.tU1g the prob..lbihl) lor fall\ In In
LhtlrllLl! ... ilh
~! \~';I)lmu~!I\-d"""llm~ ,)Ider adul h Ph)"!> 111er 77812. 1997.
J( ..u-K.! "ll.lrhrougll J. l"t' 01.1 fllulllUlCmOr) ' t0p\'\4ICh to Ol(ot: Uf,- IIessmenl of upper- limb movements . Phy" Ther 78:3. 1998. 33. Russell. DJ . CI al : Training users in the gro"s mOlOr function measure: Methodological and practical Issues. Phys 'nler 74 ;630. 1994. 34. Eastlac k. ME. et al : lnlcrra ter reliability o f videotaped observatio nal gait-analys is assessments. Phys The r 7 1:465. 1991. 35 , Krebs. DE: Interpretation standards in locomotor studies. In Craik. R. and Oati s. C (cds): Gait Analysis: Theory and Application. Mosby-Yearbook. St. Lou is. 1995. P 334. 36. McGinley. JL. el al: Accuracy and reliability of observational gait analysis data: ludgment of pus h-off in gait after stIoke. Ph ys Ther
83:146,2003, 37. Sluberg . WA , et al: Comparison of a clinical gait analysis method usi ng videography and temporal-distance measures with l6-m01 ci ne matography. Phys Ther 68: 1221. 1988. 38. Levangie. P. and Nork..in. C: 10int Structure and Function: A Compre hensive Anal ysis, ed 3 . FA Davis . Ph ilade lphia. 2001. 39. Nelson. A.J: Functional ambulation profile. Phys "Ther 54: 1059. 1974. -l.0. Harada. N. et al: Screening for balance and mobility impainnem in e lderly individuals living in residential care fac ilities. Ph) S The r
75:462. 1995. 41. Wolf SL. Catlin, PA. and G3ge. K:
Esta bli~hing the reliability and v:llidity o f meal>urement s of walking uS1l1g the Emory Functional Ambulation Profile . Phys Ther 79:1122. 1999. 42 . Shields. RK , et al: Re IJabihry, validity and responsi\eness o ffuncti onal lesll> 111 patients .... ith tolal joint replacement. Phys Ther 75: 169, 1995. 43. The Guide for Uniform Data System for Medical Rehabilitation (indudi n2 the FIMtm [mlrument), Ven-ion 5.1. U n i\("~lt\ of Buffalo F'Oundauon AClivitics. Inc. Amherst. Ne .... Yo rk. "997. 44. Santa Clara Valley Medical Cen ter (2004 1. The Center for Outcome Measure me nL~ in Brain Injury ~CO;\ IBI). hnp: //\\ v. v. .tbims.orglcombi lAuglbl 1" ::!(X).; ). 45 . Ol1enbacher, KJ. CI al: lnterrater ag reemem and :.ta biJiI) of the functional lIldependcncc mca:.urc for c hildren ( WeeFl~I): L~ 111 chI ldren \\llh de\dopmemill d lsabi hlie..,. Ar..::h Ph\s \ted Rehand 78:\309. 1~97. . ~6. \Vool:teou, \IA . and Tan~. PF' B:ibnce comrol dunn!! v..tllmg in tne o lder .tdult: R... ~aJ\:h .:md it" tmpb(' ,Ulum Pb), Th~r 77:646.
1997. ~7 . Dj Fabio.
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1'\3. O'~hca. 'i . \I1om\. ~F_ illlti l.m-.ek. R: Dual ,!\.k tnlt.rfert'lll;e .... tng gall tn people \\ ith Parktn\.On·'i di3('asc' EIJect" of mob' . . . . cognltt\'c ..('cc)nd:try 1I1."k ... Ph )'~ Ther ~2:~S8 . 2(X)2. ~4. Evan ... ~fD , Goldie. Pt\ , and 11111. KD S),qCmaiIC and randaa:t emir In repealed mt"a~uremc nl'" 01 tcmpmu l and diSlance PfWIIIte;. Ie.... (If gall .. rter ~froL e. Arch Ph}' \!ted Re habll 78;725. 1997. s,. HUllema, OB . "INt:, t\ Jlm,;u1 "to!. 1 ulute lue-d,. 111 ~",I.II'l"h ...... Rc:lnt'N , l IlrT ~ IHll Hf\ ....... ~ .m.t 'fl:,nlt.II'II.':p,jl,;
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Jre..u "'~ cl,pendllure during 30lhularion in dysva,o;;· II I T\lrNlrTl. I" e " . nd rrouOl:lUC t'lClov, -lnec ampulee .. : A COmp3r1. ~On (I f live af 3 ful , • ret! J Rchat'ol1 Rc~i\. ,999 Il~. 8(1\\1.'11. TR . ('I at: Varubdll ~ of energy -consumption mea ~ure~ in
chdJrcn \\llh (en'br:ll p31,,) . J Pedlafr Ortllop 18:738. 1995.
119 IJzrmlan. ~I J. 1.'1 al: vahdlty and reproduc ibility ~f c nrtc h force a~d hean mlr nK'.L'Uf\.' ment~ 10 :t..."C ... ~ energ y expcndJture of pamplcgiC tall Arch Ptn" Mcd Rehabll ::sO: 1017. 1999. C(I IJU'rm:ln. ~1J: and Nene. AV: Fea~ibili t~ of the physIOlogica l cost mdr, ii' an outcOllle OlI:'JglC ambulall('>n and II' Implications for functIonal e lectrical !illmulall(ln ,FES) \\all..rn~ 'y,>ten1i>. Pro~ thet Onl1011m 19: 108, 1(0)
!~5 Hood. \'l,
el al: A nt'\\ IIlcthlIJ uf u,mg hean mle to rc presem energ) expenditure:': The Total !-lean Beat Index . Arch Phy, Med Rrhabl! 83:l26fl. 2002
!!6 Til1anO\l. EB . c'1 al: Gait t:harac l en,>lIc~ and functional ambulation rorofile III pallent ""h chrome Unilateral ' tro!..e. Am J Phys Med
Rrhabll K2:778. 2()O). 1~7 Bat't. HR. and \\-{)lr SL. Modified Emory Funct ional Ambul:ltion Prolilt : An nu\(ome Illea~ure for re ha bllnat lOn for 1)Oi>! stru!"c gait d;~tun\.llon Stroh, '~:cssme nt measure (FlM + FAM) in head inJul') rehabilitatio n: A psycho metric analysis. J Neurol Neurosurg Psychiatry 67:749. 1999. 129. Donaghy. S. and Wal-s. PJ: Interrnter re liability of the Functional Assessment Measure in a brain inj ury rehabihlali on program. Arch Phys Med RehabiI79(10): 123 1. 1998. 130. Rc:smd . B. el al : Measurement of actiVity in o lder ad ulld (',.i~~ ~<Jt.c'l'tS
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():rap,,,1 beglll" by dc :>cnblllg the p~ll it:'I11'" problem III IUJll.. !Ional lenn .. ohtdt neO from the palJelll hl .. IO~. l~rtllf1lllllg a ~) . . tcnh re' ,ev. ,1110 dd funni un Icfer~ to the affective skill s and copi ng ~[ra[egle'l nt::eded 10 deal w ith the evayclay " has, les" as we ll a~ the more trcss a UIlI4ue bod y 01 I..no\' IetJ ge related to the itie nulic,ltl 01l , Jt' medl<Jlum , ..tml pre Vl'lHion o f m O\t'Tllt:1l1 d Y!o. lu llui on. Thu .... IhC') have Iraditi onall y bee n 100'nlvl:d In the l''' aOllllalHm o t phy~ i (; al lunclioll. Olht! f rnem be r~ oj Ihe reh abilitati on II.'~tlll , JI1(,: ludin g the l)(X Ur, t-
377
tional therapi st, nurse, rehabilitati o n counselor, and recreational the rapi st, are a lso typically invo lved in administerin g and int erpretin g fun ct io nal tests. Some formal in strum ents were des ig ned to be compl eted collective ly by the team . Oth er tests are c ompiled in separate sections by spec ifi c health profe ssional s and ho used together in the patient 's c hart. Where team s exi st, ph ys ical therapi sts are
typicall y responsible for the testin g of functional mobility skills (FMS) , that is, bed mobility, transfers, and locomoti on (wheelchair mobility, ambulation , negotiation of stairs and graded e levation s, wa lkin g for lo nge r di stances in the
community ). A typical ADL or IADL battery may be administered by a physica l therapi st alone o r cooperativel y with other hea lth profess ional s. When overlap among team m embers exists, fo r exampl e, the performance of toilet
transfers. the data may be collected by the phys ical therapist, an occupational therapist, or a nurse. [n these instances, testing should be coordinated to reduce duplication and unnecessary pati e nt stress. tn nonin stitutional settings or where there is no team , the physical therapi st is often respon sible for de termining all aspects of phys ical function.
Testing Perspectives Function tests can utilize two highly divergent perspectives on what is to be tested or measured by the ph ys ical therapist. It is extre me ly impo rtant that the therapist detennine in advance whether data are needed to describe the habitualle\'cl of a patie nt 's ability to do certain tasks and activiti es. or to identify the patient's capacity to perfoml certain tasks an d acti vitie s, w he ther the patient habitually perfom1 s up to that level o r not, o r even perfonn s them at all. These divergent viewpoint s directly affect what types of tests and measures should be chosen and what parame ters of measu reme nt are appropri ate to yield data useful to making c linical judgments. Most impo rtantly. physical therapi sts mu st con sider the differences between capac ity for func tion and habi tua l func tj on in determining the prognosis for rehabi litation and estimati ng the likelihood of the success o f an inte rvention. Patients accept a therapist's recomme ndati o ns regarcling the anticipated goals of treatment o nl y if there is the perceived need and motivation to function habituall y at the highes l leve l of abili ty. Understanding the difference lktw~en what a person actua.lly does o r \vould be willing to do and what thai pe rson potentia lly co uld do is an es sen tial component of designing realistic . and ac hievnbk. fun c tional goa l ~. Fo r example. eve n thoug h a per\l)n migh t howe the capaci ty to climb stairs, there may 1101 be any willi ng nc!\s to do so. Ultimatd y. phys icaJ thentpi ... t3 Jl1U ... 1 abide by each patient'::. 0\\ n dcdsion rt!garJing \\ Ili eh l a~h and activities will be incorporated into a daily routin e ant! v.'hat is a meorne, or a grea t dealT). The o ther approach quantifi es Ih e frequ ency that the diffi cult y is cncountered (e.g .. " How o ften do you have difficult y putting o n your shoes? Never. sometimes. vc ry often , or always?"). Often it is helpful to qualify a person's performance by li nking observations with non ~ pec ifi c indicators of impairments such as the energy consumption required to complete the fun ctional task and the degree to which patients must exert themse lves 10 engage in the activity, S imple measurement s of a patient's phys iological response 10 activity generally include heat1 rate. respiralory rate, and blood pressure, both at rest (baseline measurement s) and during the most stress fu l elements of the fu ncti onal task. For example. " heart rale increased to 100 beats per minute with independent ambul ation on stairs; no increase in respiratory rate." In addition. the patient's perce ived fati gue. perceptio n of exert ion, and overt signs of phys io logical stress. such a.."i shortness o f brealh , al so should be noted . These notations Ill ay assist the therapi st in a quick identifi calion of some obvious impa irment:-. Ihat limit fun ction. which shoul d be fo ll owed by more spec ific tests and measures of impainnent. Additi onal descript ors fr~q u e n tl y lI sed ro qualif) fu ncti onal performance furth er includ e ( I ) pain , (1 ) flu ctuali on . . acco rding to Ihe tillle o f day. (3 ) medicatio n le ve l. and (.t) environ men tal intl ue ni..'es. Any be tars that modi fy a patient 's fu nction shnuld bt: card ull y no ted and l'onsi dcreel b) the ph):-. ical { h e ra pi ~ 1 evalua ting c,\all1i nali on data.
Quantitative Parameters The timl' il tal,.l,;" 10 comp lele a :-.ene:-. of fuol.: li onal al·tl\ 1t1(::-, 1:\ o ftt: n U ~t'd 10 (' nh;l1ll:e .1 thcrapi .. t' ... q u.lll llfi catio n of lunr ti o ll \\ hell a g ive n ' peed 0 1 performa nce '" requ ired or an nn prme mt: Jll In pcrlOllllanC(' -:.peed j , e~pel· t ed . A COI11 lll l Hl e\drllp k 1I1 tllned functl onJ I "\"i ll s IS found in pre- ,md po,l-medi catIOIl pe riollnanCt' 01 Indl\ Jduah "ith Park i n ~o" .... d l..t~~ht· '" hu art' pl.lCl't! on L-dopa Iht'fi.lpy. E\am pl e ~ of adl vi ll t::\ that lll 'l) be IImt'd incl ude ( I ) wa lk ing a ,el d l ~ IiI Il L'l.~ l~ ) \H ll111g Olll· .... 'lgn,lIUfl'; ( .') Lionn l1l g an arude o f d~, th r ll g. ,t11d Hl cro~' Ul g a 't ree t during the ti l11 ~ of a " Wall,. " light SLu rt:~ o f ti 1l1ed te . . !....... ho uld nut be la\..cn a~
380
Ph ysica l Reh abili ta tio n
..
Box 11 .1 Functional ExamInation a n
d I
. nt Te rminology mpalnne
OEFL"ITIONS . rf :!I kill safety with no one present. . ' . I Independent: patient is able consistently to pc OIm · . .I obabi lity o f palt ent having a problem requw· . . h" '5 reach as a precaul10n. ow pr ::!. Super vision: pati ent requi res someone W it In ann iog assistance. . . . I d . cd but not touchi ng patient: full anention on 3. Close guardi ng: pe rson ass isting is ~s ~ l ioned . as If to assIst. with lall S rals pat ient : fa ir probability orpatic" ! requmng ass lSlance. . 4 Cont act guard in g: therapi st is positioned as with close guarding.
.hh W it
d ' on patient but not g iv ing any ass istance: high an s
probability of patient req uiring assislance. .' "thout ass istance Mini m um ass ista nce: pati ent is able to complete majority of th~ ~CII V I.ty WI . . 5. . I t f the activity Without assistance. fl Moder ate assista nce: pat ient IS able to comp ete par 0 ' .. 7. Maxim um assista nce: patient is unable to assist in any pari of the actI vity.
OESCIU PTIYE TERMINOLOGY '\ Bed mobility I . Independent- no cuin gI' is given
2 Supcn·ision .l Minimum ass istance
} may requi re cues
.t. Moderate assistance
5. Maxi mum assistance B Transfers. Arnbul at ion
Independe nt- no cuing is given 2. Supervision -'. Close guardi ng . t Contact guarding may requi re cues 5. Minim um ass istance 6. Moderate assistance 7 Maximum assistance C. Functiona l Balance Grades I Nonnal Patient able to maintai n steady ba lance wi thout support (static). Accept s max im al chall enge and can shift weight easily and within full range in all directions (dynamic). , Good Palient able to maintai n balance without support . lim ited postural sway (static). Accepts moderate challenge: able to maintain balance wh ile pick ing Object off fl oor (dynamic) . '. Fair Palient able to mai ntain balance with handhold "uppert: may requi re occassio nal minimal assislance (static). Accepts minimal challenge: able to main tai n balance whi le turn ing head/trunk (dynamic) . . 1. Poor Patient requ ires handhold and moderate 10 maximal ass istance to maintain posture (static). Unable to accept challenge or move without los", of balance (dynamic). 5 No bal ance "1~I)e'" 01 cue\: \'crb<J1. vl"ual. or tact llt' . In ,nnlC ;n,tance ... (e.g. , a per,on \1 ITh a memory detinL .,hOrl allen .. IJOn. leanllllg d l "' t o f ite m~ . A :>,core uf B in tht: K,lIZ Index. lor n.tlnp le. 1tl~,ln" Ihatt he ind lviJ ua l i ~ indl' Pt ndcm In perfuOlllng a ll hut one III Ih e .., i>. ba ~ i c A DL categurlc..,. On the ot her hand , :J "cort' 01 D mearh tha t the IndJ \ ldu I .1 . • u I') lllucpc ndl.'" n! III all bUi balhlll g , drt''''''' I1l 1;? , ~U1d lint' JddJl IOJl;tl JUllctlO n T hl' cOlllh lll Y Go-,man -Hedstrom and
388
Physical Rehabilitation DISCHARGE' GOAL
ADMISSION'
SELF-CARE
Svensson have shown strong construct vali d ity between items on th e Barthel and item s on Ihe FIM thai measure
fun cti onal Iimitations.3? Rasch anal ys is has been applied to the sca le sco res of the AM whi ch are o rdinal measures, in 40 order to create interval scale measurements. Tn addition.
A. Eallng B. Groomin g
C. Bathing
the Wee FIM, an 18-i tem instrumenl based on the FIM, has been developed for use for chi ldren between the ages of 6
D. Dressing - Upper
41 mo nth s and 18 yea rs.
E. Dressing - l ower
The Sickness Impact Profile
F. TOlletlng
SPHINCTER CONTROL G. Bladder
H. Bowel
TRANSFERS I. Bed , Chair, Wheelchair
J . TOilet K. Tub, Shower
LOCOMOTION L Walk,MIheelchalr
M. Stairs COMM UNICATION N. Comprehension
O. ExpressIOn
SOCIAL COGNITION P. SOCial Interaction Q. Problem Solving
R Memorv
The Sicklless IlIIpac/ Profile (S IP ) was developed to address
B BB
~
W-Walk C·Whee lcha lf B- Both
~ ~
B~~~B
B B
V-Visual B-Both
BB~BB
~
V-Vocal N·Nonvocal B-Both
~ ~
• Leave no blanks Emel 1 If not testable due (0 fisk.
FIM LEVELS
detect small impacts of i llness. The SIP contains 136 items
in 12 categories o f act iv it ies. These in clude s leep and rest, eatin g, work . home m anageme nt. recreation. ambulatory mobilit y. body care and move me nt. social interac tion, alenness. emoti onal be havior, and comm unkation. A sample SIP measure of affec tive func ti onin g specifi c to emotional behavior is prese nted in Table 11 .4. The ent ire test can be either self-admi nistered or admin istered by an interview in
Table 11 .4 Sickness Impact Profile (SIP): Affective Function Please respond to (check) only those statements that you are sure describe you today and are related to your state of health, 1. I say how bad or useless I am; for exa mple. that I am a burden on others. 2. I laugh or cry suddenly. 3. I often moan and groan In pain or discomfort .
4 I have attempted SUICide.
No He/pel 7 Complete Independence (Timely. Safetyl 6 Modified Independence (Devicel Helper - Mod/fled Dependence 5 SUpenilSIOn (SubleC! "" 100%1 4 Mlmmal ASSistance (Subject = 75% or morel 3 Moderate ASSistance (SubJect::: 50% or morel Helper - Complete Dependence 2 MaXima l ASSistance (Sublect 25% or morel 1 Total A::,slstance Of not testable (SubJecl (ess than 25%)
=
Figure
the need fo r an instrum ent th at was prec ise enough to detect meanin gfu l changes in pe rce ived func tion.42--47Intended for use across types and seve rities of illness. it is des igned to
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I ml"rill O..t\" )l'IIUI fl.kJll.ll l lUdlC''' th ,1i dt: C)ni bc till' he a lt h ~ Iatus and ph)" "..·.11 l und ll1 l1 lng o f P,II I(, 11 1'> \\Ith.1 \:lJit' t) of Impai rIIIl·n[.., r,:u'l\ Ing ph) ... tl..'.li tht: lil P) "a\ I l·t'~.Cll f)()
·WO
Physical Re h a b ilita tion
Table 11.5 Outcome a nd Asse ssme nt Infonnation Set (O asis): ADLiIA DLs
.
. . shing face and hands, hair care , shaving or (M0640) Grooming : Ability to tend to personal hygiene needs (I.e. , wa make up, teeth or denture care, fingernail care). Prior
Current
o
o
o o o o
o 0 0
'd d w',th or without the use of assistive devices or adapted D-Able to groom se II unal e , mel hods. bl t i t . 1-Grooming utensils must be placed within reach before a e 0 camp e e grooming
activities. 2-Someone must assist the patient to groom self. . 3-Patient depends entirely upon someone else for grooming needs. UK-Unknown
(M06S0) Ability to Dress Upper Body (with or without dressing aids) including undergarments, pu llovers, front·opening shirts and blouses. managing zippers, buttons. and snaps: Prior
Current
0
0
[J
0
0 0 0
0 0
D-Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance. 1-Able to dress upper body without assistance if clothing is laid out or handed to the patient. 2-Someone must help the patient put on upper body clothing. 3-Patient depends entirely upon another person to dress the upper body. UK-Unknown
(M0660) Ability to Dress Lower Body (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes: Prior
Current
0 0
0 0
0
0
0
0
0
O-Able to obtain, put on, and remove clothing and shoes without assistance. 1-Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient. 2-Someone must help the patient put on undergarments. slacks, socks or nylons, and shoes. 3-Patient depends entirely upon another person to dress lower body. UK-Unknown
(M0670) Bathing: Ability to wash entire body. Excludes grooming (washing face and hands only). Pflor
Current
o o o
o
o
o
o o o
o o
o o
D-Able to bathe self in shower or tub independently. l-With the use of devices , is able to bathe self in shower or tub independently. 2-Able to bathe in shower or tub with the assistance of another person: (a) for int~rmittenl supervision or encouragement or reminders, OR (b) 10 get In and out of the shower or tub, OR (c) for washing difficult to reach areas. 3-Participales in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision. 4~Unable to use the shower or tub and is bathed in bed or bedside chair. S-Unable to effectively participate in bathing and is totally bathed by another person. UK-Unknown
(M06S0) Toileting : Ability to get to and from the toilet or bedside commode. Prior
Current
o o
o o
o
o
D-Able 10 ge~ to and from the loilet independently with or without a device. 1-When. reminded , assisted. or supervised by another person able to get to and from the tOilet. ' 2- Unable 10 get to and from the toilet but IS able to use b d 'd ad (with or without assISlance) . a e SI e comm e
(~
Chapter II Examination of Functional Status and Activity Leve l
391
Table 11.5 Outcome and Assessment Infonnation Set (Oasis): ADL/ lADLs (continued)
o
o
o
o
o
3-Unable to get to and from the toilet or bedside commode but is able to use a bedpan! urinal independently. 4-ls totally dependent in tOileting. UK-Unknown
(M0690) Transferring: Ability to move from bed to chair. on and off toilet or commode. into and out of tub or shower. and ability to turn and position self in bed if patient is bedfast. Prior
Current
0 0 0 0
0 0 0 0
0
0 0
0 0
G-Able to independently transfer. 1-Transfers with minimal human assistance or with use of an assistive device. 2-UnabJe to transfer self but is able to bear weight and pivot during the transfer process. 3-Unable to transfer selt and is unable to bear weight or pivot when transferred by another person . 4-Bedfast, unable to transfer but is able to turn and position self in bed. 5-Bedfast, unable to transfer and is unable to turn and position self. UK-Unknown
(M0700) AmbulationlLocomotion: Ability to SAFELY walk, once in a standing position, or use a wheelchair, once in a seated position , on a variety of surfaces. Prior
Current
0
0
0
0
0 0
0 0 0 0
0 0 0
G-Able to independently walk on even and uneven surfaces and climb stairs with or without railings (Le., needs no human assistance or assistive device). 1- Requires use of a device (e.g., cane, walker) to walk alone or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces. 2-Able to walk only with the supervision or assistance 01 another person at all times. 3-Chairfast, unable to ambulate but is able to wheel self independently. 4-Chairfast, unable to ambulate and is unable to wheel self. 5-Bedfast, unable to ambulate or be up in a chair. UK-Unknown
(M0710) Feeding or Eating: Ability to feed self meals and snacks. Note: This refers only to the process of eating, chewing, and swallowing, not preparing the food to be eaten. Prior
Current
o
o
o o
o
o
o o
o
o
o o
o
G-Able to independently feed self. 1- Able to feed self independently but requires: (a) meal set-up; OR (b) intermittent assistance or supervision from another person; OR (c) a liquid, pureed or ground meat diet. 2-Unable to feed self and must be assisted or supervised throughout the meal/snack. 3-Able to take in nutrients orally and receives supplemental nutrients through a nasogastric tube or gastrostomy. 4-Unab/e to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy. 5-Unable to take in nutrients orally or by tube feeding . UK-Unknown
(M0720) Planning and Preparing Light Meals (e.g.. cereal , sandwich) or reheat delivered meals: Prior
o
Current
o
o
o
o o
o
O-(a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regutar basis b~t has not routinely performed light meal preparation in the past (i.e., prior to thIS home care admission). 1-Unab/e to prepare light meals on a regUlar basis due to phYSical, cognitive, or mental limItatIons. 2-Unable to prepare any light meals or reheat any delivered meals. UK-Unknown (conIinu .7 at al[ time pOints except for Vitality at 1 month ~ .68 and General Health at 3 months = .66
Construct validity examined with Barthel Index, Canadian Neurological Scale and MiniMental State Examination. Strongest correlations were between Barthel Index and Physical Functioning and Social Functioning subscales.
Findler. M, et al,72 2001
Cross-sectional
597 participants of whom 326 had a traumatic brain injury (TBI) who were at least 1 year post injury
Residents of New York State
Internal consistency of scale scores for individuals with TBI .79 to .92
Yip, JY, et al ,13 2001
Compared with Beck Depression tnventory, TIRR Symptom Checklist and Health Problems Ust. Significant correlations were found between the SF-36 scales and the other measures.
Cross-sectional
32 persons 60 Community years of age and dwelling older older and their adults recruited proxy respondents from senior hous· ing programs, assisted living facilities and senior centers
Correlations for scale scores of respondents and their proxies .31 to .84
Not addressed
Comme nts
(continued )
396
Physical Rehabilitation
Evidence Summary Box 11.2 Reliability and Validity of the SF-36
Andersen, EM, et al,74
(Con ,; nu. d )
Study Design
Sample
. Seiling
Longitudinal
128 nursing home residents with scores of 17 or more on the Mini-
Nursing home
1999
Reliability
Validity Convergent valtd· ity 01 physical health scales with activities of daily living index from -0.37 to - .0.43. Mental health scales correlated with Geriatric Depression Scale (-0.63 to -0.71). No SF·36 scales correlated strongly with the Mini·Mental State Examination.
1 week test·retest for scales from
.55 to .82 (ICC)
Mental State Examination and al least 3 months residence
Hobart. JC. et al.~5 Cross-sectional 2002
126 males and 51
Three hospitals in
females with stroke at time of admission; mean
Indianapolis
Not addressed
age 62 years
m ... trul11ent\ C'xulll lJling phy::. ical function.-h No in ... trume nt meaIOn
\11 lunclJ oll . Iht'
thl"r"lpl ~h
i1rt.~;1
o f \: \ .... n1l I1 ~ : -:. tt' lll \
u,,>ed III
1Ul1l' Il(JI1 al lI1 ... trum en h . \\Ihal are ... ome t'unlllion
error, In 1flh.'fPI de wng and IIlJll'ah: how .trJd
w hen you coul d use eac h of these ins tru ments with the proposed popu lati o n. Describe the advi.lntages and d i ~ad v antage ~ o f e urface~ al time o f di scharoe from the ho\ pital. 0
Funflional Status: Impaired bed mobility (modified rnd~pendence de\ ice). s it-to-~Iand. tr~msfers (minimum as . . I:,lance). Hume Em ironment : The patient li\ es a lone in a fifth~loor apartment in a buildlllg wilh an e levator. The liv109 . . pace i!o! a Ollt"-bedroom apartment on a single le\ el. Patienl Go·1f .. TI .. '. "'i . le p,lIlem I'" t~\ t reme l ) motivated to o nce ag'lI) b I • r e an 1Il( ep("nuent l11ana1!e r of her per. . onal car~ '111U ho ~ h Id • U"'t: 0 m.tna,geme nt needs. The pro . . tlh: IH.: rl'pIJI..'l"ITIL'11 1 ha . . ",uL'ce-s ... ful ly relieved IlHl l' h o f Ih ~ I' l .•tln l'\perienl..'eti In the hip prior to SUI1!tT) ~ 1110 ... , 01 h ~r . I .. . l Lum:nt l h co mfort t~ described as Illlllor ,md a"'~OL'l lt " I . h I . • .... \. \\ II I le \lI r~ucal incision). She \'Qu ld ..11 \0 I,"-l.' 10 ' . rt turn to her tamily, \olunteer, "'O\.I.tI , Jnc.J k'l\ure ' ..tlll\ tIIC,>. Sht' i ... \ cry determined 10 (I I ~t:onll nlle rhe I lOme C~tn: a ...... I ~ !lnce as soon as PO~"'lble '
GUIDING QUESTIONS I . B..t . . eu On Ihe tinulIl ' f h . l'll ...... the I' t I~, g~ u I ~. IIlJlI ..I e:\.Jl11i nalion. disIIh.... UL'mecn Ih . ,. . IlOnal 1111111 ' . l" pallem ... Impalnnenls. f1.ux'JUOIl\, Jnd J b I· . N . .".. I It) a~ presented U1 lbe dgl
l1loJd of
thl~ pro~:e~::, of lh ~..tblemcnt.
Chapte l'" 11 Examination of Functional Status and Activity Le\'el I d~!lIif)' Ihe ~ peci fi c ADL and IADL s kill s thai would
nced to be cxa min ccl lo return thi s palienl to the high ("t Ie\cl of fun ction and achieve the patient'~ goal~ for rehabi litation. Di .,c u ~s the appropriateness of the
399
in struments pre sented in this ch apte r for m easuring her function and documenting the outcomes of patient management.
References Am1 4'1 k5. IW4
21 1"j,!t:J I" D,
~3
cI
"I kdl"blltt) 01 phy .. it.il pertomlUIKt anti sc llrcllVncd
~UlllltfIUUIIllt.:..t'UlC' III "1I olda roru1auoll J Gerontol "iY2~5, 19yX
,,1dIH:JIlC) F .tnd Boll.hd. 0 l-unl'tIOIl,,1 o:\ .. llJ..rIJOIl. fh e B.lnhel 1!I'b . Md Mt:d J 1461 1965
24. Gucc ione . AA. e l al : Defining arthritis and meas uring func tional "wtu.\. in e lder,: Methodological issues in the stud y of di"ea~ and di:,,,billt). Am J Public Health 80 :949. 1990. 25 . Standards for Te,t, and Meas urement s in Phys ical The rapy Praclice, Phys Ther 71:589. 1991 26. Ponne y. LG . and Watkins. MP: Foundaliom of Clinical Research: Applications to Practice. ed 2. Prentice-Hall Heal1h. Upper Saddle Ri"'er. NJ. 2000. 27 . Granger. CV. el al: The Stroke Rehabilitation Outcome SlUdy-Part I: Gener,,1 Descri ption. Arch Phys Med Re habil 69:506. 1988. 28. Granger. CV. e t a l: The Slroke Rehabilitalion Outcome Study: Part II. Relative mcrih of the 10t,,1 Banhel Index score and a four-ilem "ubswre in predicling paliem outcomes. Arc h Phy~ Med Reh"bil 70:100. 1989. 29. Granger. C. CI al: Outcome of Comprehen~ive Medical Rehabilitation: Meru,urement by Pulses Profile and the Banhel lndex. Arch Phys Med Rehabil60:145. 1979. 30. KalZ. S. el al : Studies of illness in Ihe aged. The lndex of ADL: A standardized meas ure of biologica l and psyc hosocial function. JAMA 185:9 14 . 1963. 3 1. Katz. S. et al: Progress in the development of the Index of ADL. Gerontolog is t 10;20. 1970. 32. Liang. M. and Je 1te. A : Meas uring functional abil ily in chronic anhrilis. Anhrili~ Rheulll 24:80_ 1981. :n. Branch. L. el OIl: A prospective sludy of fu nct ional statu ~ among community e lders. Am J Public Health 74:266. 1984 . 34. Guccione. AA. and JCl1e. AM: A.~!>essing limilations in physic,,1 function in patient' wi th anhritis. Arthrit Care Res 1:170. 1988. 35 . Granger. CV. el al : Ad\tJl1ces in functional as~ssment for medical rehabilitation. Top Geriatr Rehabil 1:59. 1986. 36. Granger. CV. d al: Functional as:.essmcm scales: A s tudy of l>er!>ons with ll1ul1iple sclerosis. Arch Phys Med Rt:habil 7 1:870.
1990. 37 , Guide for the Unifonn Dal;) Sel for Medical Rehabilitation (Adult F IM ). Version -1 .0 . Buffalo. Unifom l Data System for r>.'ledkal Rehabilitation. UB Fotlndalion Activities. Inc. 1993. 38. H ~ ueh . IP. ~I al : Compari:.on of the ps),chomelric characleriqlCS of the functional mdependence measure. 5 ilem Banhd index. and 10 Item Banhel index in palients with stroke. J Neural Neurosurg p,ych iarry 73: 18X . 2002. 39. Go,man-Hed:.trom. G . and Svensson. E. Parallel rel i"bilit) of the fun ction:.!1 indq}~ ndence measure and the BaTlhel AOL index . O,,"bll Rehabll 22:702. 2000. 40. I-kinemann. AW. et ,II : Relatlon~hip~ bel\\cen ImpaiTlTl~l1t and physIC;II d"abilily a'i mea ~ ured b} tht funt·'lon.!1 IIldependence measure. Ar~' h Phy .. !\led Reh:lbll 7--l:566. 1991, ...j I. Ol!(·nbacher. KJ . e. :1 1: r-. I ~a. ed 1 O\lord llll\e r'll) Prc: ~~ . ..... .:'" ) 0r'" 1'Nf,
Nidc l. ~ IK . et al · Ch ..tn gc:~ Ifl m"lrumcnt31 aC11\ ilie!) of daily Iwingms. .Lbt1J1~ ,Lrler IrC:,ltm.:m Ot dc:prC'~, i \(" ~\ mploms I elderly women Vtlth chrUlllc L11u:.'ulo~"el("I,1 1 p.iln. A doubk-bll nd. placeoo:.controUtd tnal . Aglllg ("1111 bp R ~ .. 17(41: 293. 2005 . Pel'! . C. ct a l.-\. "~(''>' lll g mnhLltt) III o ld.:r ..dull!>. The UAB St~ of h Ae lllg, Llk·Spal.c A :. ,(·,~ntc:1lI Ph), Tht'r S5( to): 1008..2005. '; ..t\er. l( ..tIlJ Allan . OF C ,m."-ft"n' L\ e r amI ..:aregl\e r assessrneotS of lunlllOlllllg : Arc Iltc:rc: gC:lLdc:r I.Jttterent ..,,!)'l Can J Agmg '4(2):139. 2005 . \men e" "1 lR c:t at Cn I1lpar.III\ ... \;\ IIUII\ • of ",\en ....:onng sy.',U·ms ,-.~ IUI_ 1Il"lrulLh.·m.tt a, IL\ IILi:" ,)1 Jat1~ 11\ mg ,.::tle In rural elders. Ai'OI ~knt II l'.t lth 10, II 40 ~OOh
C HA P TE R
12 LEARNING
OBJECTIVES
1. Iden ti fy the roles and res ponsi.bi iilie s o f the . physical therapist in exami natIon of the ph Y' l ~ cal env ironmcllI. 2. Understand the importance. of environmental
accessibility in optim izing pali ent function . 3. Idemify common home. work place. and com-
Examination of the Environment Thomas J. Schmitz, PT, PhD
munil), environmental barriers that impaCi
patient function. -'. Identify the tests and m C3Su re 'i. tool s used for 231heri ne data. and data ge nerated duri ng eX3;;l inalion- of environme ntal. home. and work barriers.
5. Describe e\.aminalion in ~t rum e nl s used to measure environmental impac i o n pat ient function . 6. Identify srralegies to improve pati ent func tion
through environmental modifi cations. 7. Describe the ~cope of adnptive equi pment and a~sis[ive technology options available fo r indi vi dual s with functional li mitations and disability. 8. Recognize the importance o f an e)(am ination o f the environment within the conte)(t o f a com -
prehens j\'e plan of care.
OUTLINE Purpo ~c
Atlaptive Equipment 420
-!u:!
E\ UT\." th ;;U rna) he used b) ph ) ~ JL· ;\I thl.: rapish . Tdh l ~ I ~ . I pre~~ nt" un o\c!Tvie\\- of l·}.. ~IIl11Il,lI t \ln I.:olllponenh indudlllg (hl' t) PCll of testS and
Chapter 12 Examination of the Environment
•
~
403
Symbol for Accessibility The wheelchaIr symbol should only be used to Indicate access lor IndpJlduals with limlled mob,lIty Including wheelchair users For example, the symbol IS used to IndICate an accessible entrance. bathroom or thai a phone IS lowered lor wheelchaIr users. Remember that a ramped entrance IS nol completely accessible II there are no curb cuts. and an elevator IS nol acceSSible It It can only be reached via steps
Access (Other Than Print or Braille) for Individuals Who Are Blind or Have Low Vision thIS symbol may be used to ,nclicate access lor people who are blind Of have low VISion. Including a gUIded tour a path to a nature Irati or a
scent garden In a park ; and a tactile tour or a museum exhibition that may be touched
Audio Description A sefVIce lor persons who are blind or have low VISion thai makes Ihe performing arts. vlsuat arts teleVISIon, Video. and film more acceSSible
AD)))
....-
; •••• • •••••
-
Descnpt.on 01 Visual elements IS prOVided by a trained AudiO Describer thr ough the Secondary AudiO Program (S AP) of televiSIOns and moMors eqUioped With stereo sound An adapter lor non-stereo TVs IS available through the AmerICan FoundaTIon lor the Blind, (800 ) 8290500 FOI live Audi O DescnptlM. a trained AudiO Describer oilers live commentary or narration (via headphones and a smaillransmltter) conSI~\lng 01 conCISE' objective descnpllOns of Visual elements (eg .. a thealer performance or a Visual arts exhlblllOn)
!
Telephone Typewriter (TTY ) ThiS deVice IS also kl'lOwn as a le1l:' telephone (TI), or telecommuntcatJons deVice lor the deaf (TOO) TIY Indicates a devICe used telephone lor communlCaTton With and between deaf. hard of healing. speech impalfed and,or heaTing persons
WIth
{he
Volume ContrOl Telephone ThiS srmbol InOlcates the locatIOn of telephones thaI have handsets wllh ampbhed sound and Of adjustable volume cootrols
Assistive Listening Systems These systems lIansmlt amplifIed sound via heanng aids headsets or other d9VlCes They Include mfrared. lOop and FM systems PortaDle '")
a lecture
tour. fIlm, performance conference or other program
Accessi ble Prmt (18 pI. or Larger)
l¥ge Print
I
Tnt: ,~DOI'O' large pnn' IS large Pnnt" prmled In 18 pt Of 'alger talC! In add'tlon to IndlCallng Ihat large pllnt verstons 01 books, pamphlets r'!11.l~urr. g ••HoeS and theater programs me avaIlable, you may use the symbol on conference or membership forms to Indicate thai prmt matf:!"a'! ma, oe p!o.lded 10 targe print Sans sellf or moeiltled selll p"nt With good con trast IS Important. and Special attenTion should be paid t II;-"t and word spaCIng
j
The Inlormation Sy mbol T t rr ... tlC1 or
>I .al ,,40E commodrty 01 'COay's sex;.et;,' IS Intormahof'\ 10 a Pf'rson
,'. ~dl,
.Il'
w.," a dIsability Il lS essentlal For example the symbol may be gf'lage Of 00 a IIOO~ plan 10 IndICate the loca'lon 0 1 thtllnlormm.on or SecUli ty dtlslo. ""here thete is mole specifIC IntormatlOo Of
to'- _,,(1'1"0 acx,..tOur
OflOO when 5/;119('100 br !toe ... .ewer Tne T&Ie-otSlOn Decoder '-' ", Art 01 • r.-Q~ I _ T":...-'t$ 'A ,m screens I)" or _tlgtol to na. tf Ol. t III ~odtns as- of Jt.I~ 19!JJ AlSO videos (t1.al ate pan of )(It
or tit! ' ~l.-O' apl,)f'II>O v'l1ng ttl ~ b)'mOO! Il10 1\'' '~lr\JCtlon!c pil:SS a b..nOl1fOl captlOfllng
oc
Opened Capllonmg (OC) ,
•
·· .. ·.
I
E.
..0;
~t
101 II
'lO .all;"
'9'
Wf\>C,\ trans .31.· OlalOQVtlt J>'lCI O'ICtff $CIIIlO In pr,nl a'I:! a' .... ,j~·~ Ots.pla) eel 011 tf1e .>OOo!ao.l_ tTW)\.'. Of PI'~ r ",/I&d b, "'ilf'~ ,000oalioO o.,dl and 1001 httar -.g nc1i.!d4alS ana ~ .... "ow S8COf\O '~ - ,1 tG ",:,p1u l . , k..,), "9 en I(j!t {jraptl>C Art'ii>t:lo G .... \,j l-~... ,gn .... 1· lWJ~fl''''CI t
£na,' .... l .. AStO'l
Figure 12.1 !JI 11,,111
.n. ('
I' I' .., All
~~Itl r. 'I!
AI'
IOlhuN ..... ll\l ... · .-.ltlurtl.t!A
,,,st... ,
..... 11 j)tIIl
Oft.... IOf ~,.l. ,J..:;".SU'.,,;& by tflo:tI ::>OOtlt'( ot
"til( _1 .:is!I
404
Physical Rehabilitation
. mental may include (I) interviews, (2) "If(;·hecklisIS. questionnaires) and peiformance-based ' '1)0' S • . (3) measures 0i erwlron_ f' . (hl'en 'miml ) ojjunctlon, measlll es 0 , . d" · I on fimction. (4) vIsual ep,ctlons (photomenta I wlpac , spoce grapIIS, 1'/(.' 1eotapes) and dimensions . o/phYSlcal ., " (strue_ 'ofls) and (5) O ll-sae VI SitS. A combmatlOl1 of lura I speoijicatl '
of the environ .
.t
two ormore of th ese strategies may be warranted ,to generate all needed data. The current era of cost c~ntatnment has placed restricti ons on time and travel aJl ocat~ons for on~site visits. In such situati ons. several data coUectJOn a1ternatJVes
( g . interv iew, self-report . and perfonnance-based mease· s :, and use of photographs and/or diagrams [with dimenure sions] of the physical space) can be unplemented to achieve the goals of the environmentaJ exammatlon. Sanford et aJI I reported on a nove l cost-effective a1temalive approach lO the in-home examination. The authors com· pared data from an actual o~-site home ex~mination with those obtained from remote vldeo-confe rencmg technology. The data suggest that videoconferencing has the potential for enabling therapists to examine the patient's environment regardless of distance or locati on. The data from the remote Figure 12.2 Availabili ty of accessible services. Shopping mall telephones di splay the symbol for volume .c~ ~lro l I ~ l eph on es (le!n and the wheelchair symbol of accesslbdl ty (n~/lI) .
ex amin ation ident ified 5 1 o f the 59 problems (86.4 percent) documented from the on-site visit and 54 of the 60 quantitative measures (90 perce nt) obtained from the on-site visit. ]]
measures used. lools used for gathering data, and types of data generated. Depending on [he nature of the patient's functional limi tation or disabi liry. dala collect ion tools used for examination
Interview Expl orati on of th e environment i s typically initiated by interv iew in g the pati ent and support network members, If
Table 12.1 Environmental, Home. and Work Uob/ SchooV Play) Barriers: Types of Tests and Measures Used. Tools Used for Gathering Data, and Types of Da ta Generated. En vironmental, home, and work (job/school/play) barriers are the physical impediments that kee p patients/clients from functIonIng optimally in their surroundings. The physical therapist uses the results of tests and measures to identify any of a variety of possible ImpedIments, including safety hazards (e.g. , throw rugs , Slippery surfaces), access problems (e.g. , narrow doors, thresholds , high steps, absence of power doors and elevators) , and home or office design barriers (e.g .. excessive distances to multIstory enVironments, sinks,. counters , placement of or SWItches) . The phYSIcal therapist also uses the results to suggest modIfIcation to the environment (e.g., grab bars In the I shower, ramps , raised 101let seats, increased lighting) that WIll also allow the patien Vclienl to Improve function ing in the home, workplace , and other settings.
I
n~gotiate,
?at~rooms,
control~
Tooia U.... for Gatberinc Dua Tests and measures may Include those that charactenze or quantIfy:
Tools for gathermg data Include'
Data are used in providing documentation and may include:
• Current and potentIal barners (e.g., checklists , IntervIews, observations, questIonnaires) • PhYSical space and envIronment (eg , compliance standards, observations. photographic assessments, questIonnaires. structural speclftcatlons , technology-assisted assessments, vldeographlc assessments)
• Cameras and photographs • ChecklIsts • IntervIews • ObservatIons • QuestIonnaIres • Structural specIfIcatIons • Technology-assIsted analYSIS systems • VIdeo cameras and VIdeotapes
• Descnptlons of: barners environment • Documentation and description
From American PhYSical Thera py Assoclahon ,J
lib!!
wlth permission
01 compliance Wi th regulatory standards • Observations of environment
, Quantlflcal/ons of physical space
Chapte r- 12 Examination of the Envir-onment the pati ent 's fun ctional limit at ion s o r di ~ abilil y impac i onl y i ~o1at c d tasks or ac ti vitie s or if acce ss ibilit y isslie s invol ve limi ted e nviro nme ntal barri e rs. an int e rvie w ma y be aJl that is needed to determine the p hysic a l impe di 111 e n t ~ and provide sugges tion s a nd guide lin es fo r imprO\Iin £! perfo rman ce and reso lvin g access prob le m s. In the pr~se nce o f more fo rmidab le fun ctional limitations or di sabil ity, th e interview may be th e fir st of several stral Cgie:, u"ed to co llec t data a bo ut th e pat ie nt 's e nvironment. Th e inte rview c an be used 10 es ta bl ish the ge neral charac t e ri ~ t ics of the e nviro nment (numbe r of leve ls . stairs. railin g .... and so fo rth ). ide ntify a ny s pec ial probl em s pre \'iou~ l y enco unt e red b) th e patient. a lert th e th erapi st 10 potential safety haza rd s. and de te rmine the need for furt her te,!o, ls Jnd me asures to o btain essential infonna tion. T he int erv iew process al so provides th e therapi st an opportun it y to ga in kn ow le dge o f s u ppo rt network charac ten:o.tics ind uding ( 1) allitud e to wa rd the patient: l ~ ) the nte nt o f thei r des ire to have the pati e nt re turn to hi s or her e n\lro nme nl : (3) th e ir careg iving goa ls a nd capabilitie~l: :.Ind (-n att itud e to w patients' ab iliti es to pe rform c ustomary ac tion s wi thin their soc ia l/c ultural co ntex ts. A vari e ty of in struments have bee n developed thaI address the impact of env ironm e ntal determinant s on function. Examples of these in strume nt s include: The Physical Activity Resollrce Assessmellt (PARA ). H Based o n the close link between aspects of the ph ys ical e nvironment and physical activ ity leve ls, thi s in strument was designed 10 examine and doc ume nt the available resource s that promote activity within a ne ig hborhood o r community e nvironme nt. The PARA is used to examine the type. quantity. accessibility, qualit y, and features of physical acti vi ty resources within a patient 's environment. Home alld Comml/I/ity Ellvironment (HACE) in strume nl. 25 The HACE is a se lf-report instrument used to identify features of the patient's home or community that may impact leve l of func tion . The environme ntaJ domains exami ned include home and comm unity mobility. basic m obi lity and co mmuni cati o n dev ices, tran sporta tion factors. and attitudes .
• Safety Assessmem of FI/J/ction and the Em'ironment f or RehabilitaTion (SAFER ) tool.26 A comprehensive functional and env ironme ntal examination tool designed for use with the e lderly. It includes 15 areas of concern : liv ing s ituation. mobility, kitchen. eating. ho usehold management , tire hazards. dress ing. g rooming, bathroom, medication. commu ni cat ion, rec reation. general items. wandering. and memory aids. Eac h category is exami ned with in the content of the home e nvironment and the funclional capabililies of the patient. Usabt/iry ill My Home (UIMH ).21-.lQ This self-repon instrume nt examines fe ature :, of the home ellv ironmenr Ihat e ither constrain Of promole activity perfonnance (see Appendi ). B). It addre~ses aspects of both basic ( BADL) and in strume ntal '.I(.;t iv it ies of dail y living ( lADLl and conSi:'l", 0123 item .. , 16 o f whic h are scored on a scale of 1 10 7 ( I re pre~e ntin g thl:! m o~ t negati ve re sponse: 7 the most pos iti ve re~po me) . In addition , the in"trumcnt includes 7 open-t'nded lJUe... tio lh (6 fo r descriptio n o f specific usabil it} pro bl em:o. i.lIld I fo r e>. press ing additional opinions). Usab ilit ) i, l'o llce plually dcti ned as Iht: extent 10 which a pat ie nl ', Ilt:e j ... com· pfI"ed of t\\O Ide nti ca l! ) fo rmalled companion meas· un~"l : the Dllii< IIlty Ralillg Scale (DRSTM) and th e 4cccl'lal)/liry ROTfll!! Scale (A RS TM). Th e EU M is a 7· pOin t bipolar rating ~c ale adapted from an earlier publi'ihed and tested IS-poi nl sequ ential judgmen t scale Y It namine, the pati(:nt"~ pe rce ptions of th e comparatne ea"e or difficlllty of ta ~ k pe rfo rm ance (that may or mJ~ not be con' l"tent \', ilh th e ob~erver' 1I110rmation ca n be obta med from a \ ariel), of ..,ourcc:-:. Includ1l1g th e pall e lll, rehabilitation tea m conlerenee'l. paucl1l/1allldy and c art.:giver co nl e re nce:>. or inte r\Ie".." medic,11 record dOClIIllcn tall o n from all d l "'l' iplin e~ lIl\'uhed . .Jnd 'IoL ial ,en IL t! I nle r VICv.~. O nce thi S inlormati on 1\ gathered, dt:u . . lon . . c an be llIaJ~ conce rning \\ hal .JdaplI\l.:' or :1.')51 . . tl\ e de\ Ices \\ i II be Ih.:edcd and lhe a pprupnat l.: team membe r . . to accompall ) Ihe panent lin the \ 1') 11. I d~:.tll) glH:n Ihelr compleme ntar) t'Xpe rtl".'! alld :-.!"lIb. both the ph)"'1(:al and OLLUp:1 I1 U Il ~ 1 tht' rapl ')t .ILcomp.lIl) the p:.ttl ent on the home \ 1\11 Th~) a:-...,unh;' 'I h ~m~d re'lpon -
(' "" Ib lI"lI y f or ex'un • in ing the patient-environme . nt interface. n Ihe spec ific need s of the patI e nt and/or sup" De re n d mg 0 ' k members a s peec h- la ng uage palhoiogisl port networ ' h "" ' " I k r o r nurse a lso may be am o ng l e rehabllna· SOC13 wor e . , n Incmbcrs vis it ing the hom e. For purposes of " tulll e at . . . . " ,"on and ~truc tu re • hom e VISits are. ofte n dIVided organlza 1 •• . "l ob'll e lement s: (I ) access ibI li ty of the 11110 twO fi" ' • . , • dwe lli ng's ('xlerior a nd (2) examinati o n o :the home s mteri al'. An in ex pen sive d ispo sable c a mera IS useful for pro· vid ing images of architectura l bar~ie rs ~o accompany lette rs o f j ustific al ion for neede d. modification s. A t~pe meas· ure an d honle vis. it examina ll o n form are a lso Important 100is during the visit. Many rehabilitati on depanments deve lo p their ow n home s urvey fo rm s to m eet the particular needs. of the ir patient population. The fo rms (or check· lists) help 10 o rganize the vis it and a re useful in directing attention 10 all neces~ary de ta il s. A sa mple is provided in Append ix M . Thi s fon n de pe nd ing on the spec ific popul at ion . Some c a ut ion from home s urvey fo rm s
can be exp~n~e~ or modi~ed. need s of the m d lv ldu a l or patient m ust be used in inte rpre ting data that have no t been standardiza-
tio n or exami ned fo r rel iabi lity. On a rriva l al Ihe home fo r the on-s ite visi t. the patient may need to re st for a shon wh il e before beg inning the home examination. Thi s is an important consideration, because patien l ~ may become very exc ite d or emotional whe n re turning (0 a c herished hom e e nviro nment after a le ng.thy abse nce. This may be true eve n if a day or weeke nd visit occurred prior to the fonna l hom e visit. One me thod of gather ing data a bo ut the interior of the home is to begin with the pa ti e n! in bed as tho ugh it were morni ng. Simulation of a ll daily tasks and activities. includ ing dre:-.~ing. groom ing . bat hroom acti vities. and pre paration of meab can e ns ue. The parient should attempt to perfonn all tran~fer. exercise, locomoti on . self-care. and homemakin g 3c ti v itie:-. as independe nlly as poss ible. This w ill provide a n additional opportu nity to teach the family members and .:areg ivers how and whe n to assist the pat ien t
Patie nt- Home Environment Re lationship: Overview of Access. Usability, and Safety ex,uni.nation of the envi ro nme nt are used ac.:c~~. usabi lity. and safetY ullcr.e nllOlh. Corcoran
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Physical Rehabilitation
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Figure 12.4 Handr:lil exten,ion'> ~ h ou ld run a minimum of 12 in. (305 mm ) be) ond Ihe top and bottom edge of ramp . (From American Na li ona l Siand ards In slitute. l n c .~ · I' '7 with permi, a suitabl e chair can be found in a d iffe rent locati on within the home and moved to the li ving room. Ano ther optio n is 10 modify the current fum ilure by placing a fitted wooden board under the ~ca t c u ~hlOn and behind the seal back (if removable). If a ne\~ chair is to be purchased. recom mended features 01 the chai r ~hould be provided 10 the patien t, family member. and/or careg iver (e .g .. the he ight of the seat 0 ~ h ou l d all o\'. the knee!. to flex approximatel y 90 with the feet fl at on the floo r. a timl cushioned seal. a finn c u ~ h -
411
ioned back that provides adequate upright support. and doubl e ann rests). 4. Use o f any un sta ble furniture suc h as roc king chairs sho uld be di ~co uraged for most pati e nts. Usc of leathe r furniture sho uld al so be avo ided as it can hinder moveme nl. C hair~ that provide mec hani zed elevation o f the back of th e seat arc commerc iall y available but should be used wi th caut ion . It may be diffic ult for a patient to stabili ze the fect as the scat is e levatin g. Thi s causes the feet (a nd pe lvis) to slide forward resulting in a fall.
Electrical Controls I . Unre stricted access should be provided to wa ll switches , and elec tri ca l outlets. Power strips (s urge p rotectors) can be used to increase the number of out lets as we ll as improve access. Out le ts may need to be rai sed and wall switches lowered. Fo r indi vidual s using a wheelchair. use of pull cord extensions may allow control of some high e lectrical switches. 2. Some patients may benefit from rep lacement of standa rd togg le e lectric sw itc hes (e.g .. overhead fixtures) with rocker switches that require less fine motor skill to activate. Rocker switches are availab le with lighted surfaces and with occupancy sensor devices that automatically tum on or off upon e nte ring or leaving the room. Lightsw itch plates come in a vari ety of co lo rs and will be easier to see if they contrast with the existing wall color. For exampl e. in rooms wilh li ght colored walls (white, offwhite . beige). darker e lectrica l oulle! and light-switch pl ates can be se lected. A ground fault circuit inteITllple r (GFCI) should be installed in we t locations such as bathroom s to preve nt against e lectrical shock. A GFCI outlet acts as a mo nitor for currenl imbalance between the hot and ne utral wires and break s the circuit if that situation occurs (e.g .. fault y appliances. worn cords. or appliance contac t with water) ( Fi g. 12.6).
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Ihx ~er ~ \\ 11th (UV'II I.lhk \'. uh l i~ ltlcd ~urt;( (he lOp and bOil om of (he ~Ii.llr . . for added ~a fety.-l Ba ll ery-ope raled touc h ~ \\ itch Limp . . are a practi ca l s uppl e ment wh ere e lec trica l li g ht "oun.:e~ are una\all able. Inex pe ns ive trac k li g htin g pro\ ide . . multip le adj u..,tab le l a111p~ and req uire~ o nl y a . . ingle electrical I;o urce. Lightin g :-:. ho li id be brig ht wi th glare and ret1el'W)]1 m ini m ized. M o ti o n de tecti o n lig ht ... that c.lting ... urfal o afe ty pit'all ) po.-.itioned \\ ith [.... 0 k g:-. in the tuh alld t \ \ { \ kg " ~In the 1100r aOj. ion .. of bathroom grab bar., on the side wall (/ejt) a~d rear
\\,111 (n~hr). Val ue:>. denoted in inchc .. :md millimeters. 1lle bar~ ~houlll be mounted hOrizonta lly In . (~-W mill ) 10 36 in . (9 15 mm) from the Ooor. ( From American National Standard s Institute. Inc. ~ I'JI \\ ith pcnnl " lon.)
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Fig. 12 . 12 ). ami scald va lve .. 10 prevent wate r tem pe rature from ri sing above a preset lim it (also ca ll ed scald-gilaI'd \'oh·es or high ICIIII)t' ralure SfOpS), water vo lume-conlrol mechani'ml s (to preve nt a sudde n surge of \\ ater \\ ith re sultant ('hange in temperature) , enlarged faucet handles on the tub o r sink {sin gle- lever sys tem
fa uce ts are o ptimal ow ing to thei r ease of use). motionsenso r fauce ts, a spray attac hment at the sink (allows washing hair wi thout e ntering the bathtub o r shower), a towe l flclllllullnkrhlp KIIl;'o.'ll!:.lr.t!lU: 1),,' 11' In Ionl; I. m
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.e rc i ~t! progralll~ e.,t nV~ hnncf:) ~.ges. and Lions lmemationai) or diagno. M~·spe(;Jllc organtZatlolb (e.g., National Strole A s~iation .
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Foundation). An important consideration is that not all patienls will have current housing that is amenable to modification (e.g., an individual who previous ly lived in a third-floor walk-up apartment and noW uses a wheelchair). In such instanca, the local Ho using and Urban Development (HUD) Office will be an important resource. This o ffice can provide a list. ing of accessible housing wit hin the community. Because there are often waiting lists fo r such dwell ings, early appIi. cation is warranted. Finall y, creati ve fu nd ing fo r specific items (such as spe. cialized adaptive equipment no t covered by other resources) may be avail able through private o rganizations or foundations. Cons iderable time, research, and perseverance may be requ ired in locating a receptive organization. General sug· gestions the patient , family, and/or caregiver(s) might CIJll. sider in seeking assistance incl ude contacting local businesses or corporate giv ing offices. civic or service clubs, churches or synagogues, labor unions, Jaycees, and the Knights of Columbus.
Legislation Much attention has bee n foc used on the imponancc of environmen tal acce ss ibil ity. Through legislation and a varie ty of private organizations, s ignificant strides have been made in thi s area. In 1990 the Americans wah Disabilifies ACf (ADA ) was signed into law. This lcgiIIation is among the most comprehensive of the civil rip laws enacted fo r individuals with disabilities. It guarantee5 civi l right s protection and equal opport uni ty in the areas of govemment serv ices, employment. public transportalion. pri vately owned transportation available to the public, aelephone service. and public accommodations. 7S lbis law req ui res that all " public places of accommodation" be mtdc acces~ ible to people with a di sability un less it imposes "undue hardship" [0 the establishment. This law specifics that .reasonable accommodations be made by res~ mov ie theaters. hotels. professional offices, retail s~ aDd so fonh. With respec t [0 an individual, disability is defined in die ~D.A as "a physical or mentaJ impainnent that substIIIIiaDY limns one or more major life activities of such an indiv»~al ; a record of such impairment; or being regarded IS ..... I,~g suc.h impaimlent."7'1. p ~ Undue hardship includes eIQIIr slve d lrel.'t cost of adapting the environment. ..... resource~ of the establis hment. or s ituations wbele .... c ~anges wou ld fundamentally aller the nature ordlily,..all~n ,Of a business. Connolty7t1 suggests thal tile croat tI c hange~ c~U1ot be used as a defense during litig __ . . . the t'ina.llclaJ burden would threaten (he very e.is • tI. the buslIle>s. The ADA also provides a federal
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Chapter 12 Examination of the Environment
incentive for measu res taken by businesses Ihis law.
10
comply wilh
Til e Fair H ousing A Cf, as amended in 1988. prohibits
di sc rimination in housing on the basis of race. color. religion. ge nder. disabili ty. famili al status. and nalional origin. The aci int"ludes pri vate hOllsing. stale and local !!Ov(, nlmenl housi ng, as we ll as any housi ng that receives federal financial support. It requires landlords to allow individua ls wi lh disabililies to make reasona ble. accessrel:ucd modifica ti ons 10 their li ving space. as we ll as common :lrea~ of the building. However. the landl ord is not req uired 10 p access ible constru ction standards for multifamil y housi ng units built for first occ upancy after Marc h. 1991. The Rehahilitation Act of 1973 prov ided that access mu>t be e;tabl i' hed in all federall y funded buildings and transportation faci liti es constructed aft er 1968. The la w prohibits discriminatio n in fede ral empl oyment . stipulates accessibility wit hin federal bui ldings, and es tablished the ArchileclUral Transportation Barriers and Compliance Board. Because many federall y funded institutions provided low compliance with the 1973 Rehabilitation Act. an amendment was passed in 1978. The Comprehensive Rehabil itation Services Amendments (P.L. 95-602) of 1978 strengthened the enforcement of the original 1973 Rehabilitation Act. The Architectural and Transponation Barri er~ Compliance Board is the gove rnin g bod y res ponsible for enforc ing thi s legislati on. The Architeclllral Barrier Act of 1968 (P.L. 90-480) pro\ ided that cenain bu ildings th at were financed by federal funds be desig ned and constructed "to insure that physicall y handicapped persons wi ll have ready access to, and u!:>e of. such buildings." 77. P 719 Anot her important item of legi ~ lation re lated to environmental access ibi lit y is the Public Building' Act of 1983. whi ch functio ned to establish public building policies for the fede ral gove rnment. Thi ~ act (~ection 307) provided several amendments to Ihe Architectural Barrier Act of 1968 10 furthe r strength en and deilneale the importance of accessibil it y. The lenn [lilly accessible in thi~ act wa~ defi ned as "the 3b~ence or elimination of physical and communications barriers to ~he mgre~s. egre~s. move ment within . and use of a bui ldmg .b} handicapped per~ons and the incorporati on of such equ ipment a~ i\ nece~sa ry to provide ~ uch ingress, eg ress, mo\e ment. and u~e and . in a buildin g of hi ~ tori(', arc hi le(: l~ral. or cultural significance . the el imination of !-ouch baITIer\ and the incorpormion of ~uc h eq uipm ent in ~u c h .knl PU~~ l ble." 7k, I' 371
De::'pllc the rece nt gam!) made in architectural aCCCS~l'
blilly. barrien. continue . . lu eX ISt. Jn a'iJl1uch a~ 1ll0!)t public tri.tI~')ponallOn ~y.,te m s "'ere built before: 1968, acce1->~ib ll ny 1\ not required by I'av.. I"lowever, tIle ADA . . l'Hles thul !n(lI
437
all co ncerns that offer public transit along a fi xed route must also provide buses that are accessible to individuals with disabilities, including access by wheelchairs. Other areas that continue to be problematic include revolving doors, the desig n of many s upermarke ts and s ho pping areas (barriers imposed by checkout areas and items displayed on hi gh she lves), lack of availab le parking s paces, multiple leve ls of stairs at the entrance to some buildings, and th e des ign of some theaters and auditoriums that do not have specificall y designated areas for indi vidual s using a wheelchair. The ADA homepage (http://www.ada.gov) provides a ri ch resource for infonnation related to accessibility, planning of new constructi on. guidelines for modification of ex isting faciliti es. and answers to frequently asked questi ons about federal accessibility requirements. An ADA infonnation line (8 00.514.030 I [voice] 800.5 14.0383 {TOO]). provides technical assistance on accessibilit y standards and a 24-hour automated se rvi ce for ordering ADA material. Also available is the ADA video gallery and an ADA Technical Ass istance CD-ROM that includes regulations, design standards, and techni cal assistance. Although incre as ing numbers of buildings are being designed to provide accessibility, this area warrants further invo lvement from therapi sts. Physical therapists can be effec ti ve advocates and are equipped to provide a leadership role in compliance with existing and new laws. They have imponant knowledge and skill s to enable them to provide va luable input into the initial planning and/or modification of barrier-free des igns.
Summary Exam inat ion of the environment is an important factor in facilitating the patient's transition to the home. work. and community. The rehabilitation team uses the data to determine th e level of patient access. safety. and functi on within the environment. The infom13lion is aJso used to detennine the need for additional treatment interventions. ATs. enviTOIlI.nenlal modifications. outpatient se rvices. and adaptive ~q llipment. Ln addi tion. the exa mination assists in preparIIlg the patient . famil) , careg ive rs, and/or work colleagues it ll~ e l~lployer fo r the individuaJ'~ return to a given 'etling. rhl ~ chapter ha~ pre~ellled a sample approach to examination of the enV ironment, Common environmental fe3l ~lres Ihat Iyp icall y warran l consideration have been highlighted. InaSJ1l11L'h a, iI return to a fo rmer environment is orten a primar) goal of rehabi litation. earl y con.)ider•.uion of thc~e i !:>s lle~ is \\.-arramed. Colhlbora[ion among team membt.:r.), the I1tn:.tger of a ... mall u('(;ollnt ing lirlll [h ..11 ,he and ht' r hm.hand c:-.tub li,hed . He r hu ... band i, dl;':(ea"'c:d. She ha~ lhn!l~ gro\\ 11 c hildren \\ ho a ll li \e III nClghhonng l.:ull1lll unilte, Prior to Ihe lunc tl oll ..tI 11I1111 alion ... Impo ...ed b) the Ilip pam. the patient had heen IIlderendent III all BADL and IAIJi.. She a l'1oo \o luntel' rt'd ha dl.:t:ountlll~ ... enlt:e~ on\.' l h.l ) pl'r wed to a lnea l l' harn ) \.I,hllh pro'vldl:~ meal ... 10 huml"l)\'und lndi\idual\, , hl' \\ ,., d reguldr partlupam III lamd ) llUllllp. enJo)cd gO lll g to lhe theale r. ct)l1n:n~, and ~pcu.d 1ll1l\CUIll t'\ellh , ..IIId \\ ti\ ..Ill o.Il"Il\\;' llIl'mher 0 1 the l"tHllmul llt ) h .... l oriGti prl',eI\J . IJon 'Olll'l) KCl"enll). the..,e 4t:!t\ Hle\ had t\..1 Ix' l Urli.U led o\\mg 10 tht: IJllre.j\\;,d hip d l ~lll llltort ~he t'\:-.enthtll) h.td 1\0 .tLlI\ H l e\ oll l, ide the hOllle lor , rnolltlh prIOr 10 adml::'Moli Jnd uled a \\Ull..\.' f 10 111111 1llll.tc: wl"Jghlbedring .tIld rcdw,:c: pmn. She ..Lbo leq tilrcd Ih ... a.., .. r\tdl1le oj u hOllll M)!.;lallon GUide 10 ph }:'!cdl Iher.lpl:.1 rrdlth.x cd 2 Ph) , -nlcr tH. I. ~O(JI 4 AmcnLdIl Noil lon ... 1 Siandolub In:.II IUle. fill . American Nlllh)1II11 ~toll\duy 'n,c ('~ll1n l or U n l\e J ~ .. II.k-!)lgn. all IlIltuill \'C of tht College oj DLI,lgn . J. hlml
O~lro tT. E: Um\en..tl de \ign: Tht' n('w par.tdigm. In Preiser. W. and O:.troff. E (cd ... ): U,1I\er"al Dc,igll Handbook. McGr.t\>o · Hill. New Yor\... 200 1. p 1.3. l!\. R,ley, CA: f-h gh-Acct'\!:> Home: Dt'~igll and Decoralloll for Barrier· Fr('c L lv lOg. RlllOli Inlt~ma 'l on;ll Publications.
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11J91j 10. l..e\ HIC', D {cd ) Unl\c r~aIIXMg.n: ~t;'\\ Yvr~ . T~ Cit} of Nt'" York. f\ layor':. Offil:~' lor People ~\llh I)1' .. tlllitl t· ... Ct'nlcr fN Ih~ Irn.;lusi\·e Dc~lgn ..tnd Em lI'Ollfllclllal A~cc!:>~. Uru \'cr!>u} of BulTa!\). The Stale l hll\er:' ll) (If t"Yo YU I~ . 2(103 II S..tnford. JA . l'l al L1., mg 1.:-lcn·h.lbllll.lll{)n to ide ntlf, home modltlL.1l1un 1I~"t"(b A'~hl Tcd\JIol If)( I ):43. 2M . 12 l)un~.ln. P\\. cl,ll Fun\.·tional re.IL h Prt'dll.'II\ e \aliwl) 11\ u sample (II ddl.'rl} Illak \Clcr:.uh. J GCJ'UnIO\ ~7(3): M9] . 1992 11 i\ IJlhta... S, Nu}'.u. . US. and ba;u.·:.. 8 Balao!,;... in ddrtrly p.tlkllls: llw ·C;('1 Up .lUd GO··lc!>!. -'\rch Ph):. !\h!d Rt'habil 67(b):J87. 1~1'I6
440
Physical Rehabilitation
1-1 Guralnik. JM . et r 78(8);8~2. lQ9g. St. . Gro\~: DP. .lIld Bail ie. 1\.1(': FaCIO!";. influellc ing re~ults of fuptOoIII ( ap:II.' II) ":v;tlU,ltI Olh III \\orkL..'r1> · com pen:-'3tion daimanls widl loW b.ld pam. Ph) , rhe .. 85 (4) :3 15 , 2005. 57 FI \ hb,un . DA . 0:\ al' l\'lt'awnng rC\lduaJ fUIK tiOnat capaClIY ill dlrtUlIl' hlv. ba(']" paH1 p:tltent~ b:heu o n the Dictionan' of O,'('upatll' 1L,11 Tltk'~. SPlIll' 19\M Un.2, IY94 . )1\. U S .nlkd {o.lle~ D..:1>-IrtOlcnr of Ln~)r : OKtionary of Occupariollal l llt!.'l> . ..:d 4 . Ro:vl\~'d 11I1) I. R~'lrit'"\l',1 October 15 , 1005 froDI Imp:llv. v. \\.\),t lj dol g,l\ llibdot hl ml analy'" and on~1fe .'Jucation. Onhop Phys TIler PnlCl 5:8. 199:l. 6) . Helm-Wdll :l1m. P: Indu strial rehabilitation: Developing gUldclll1l". PT M:II!a7InC 01 PhY\lcal TIlcrapy I{J):65. 1993. 6-t " }1m. -KE: A contmuum of care 10 trc:n the injured worl.er. PT ~lagaz me of Ph),ical Therap) 2(11:52. 1994. 65 H ~bc n . LA OSHA ergonomics gUIdeline:. and the PT con ~ ultanl. PT Magallne 0 1 Ph ~ ' Ical Ther3p) 3(7):54. 1995. 66 \\'\ nn. KE: Setl lllg l'orporate tr~nd, \\ith on·:.i le PT. PT M:lgazme c.(Ph\\lc:l1 Ther:lp) 4{7l:66. 1996. 67 L:1\\~ncc. LP: Pr:lcllcing ",here Indu ~ t f)' li\'e:., PT M:lgazine o f Ph \' I(al Ther:.tp) 6(]UX. 1998. oS. Co·hn. R Direct contr,lcting: I ~ il for yo u? PT M:.tgazine of Physical The-r,lp) 7(5): 22. 1999. 09 0:1\011. SCan IIlg their !1Ic he~ : O nc-of-a· kind practitioners PT ~la gal l1le of Ph)":' lcal Therap~ 6(11):34. 1998.
61.
Supp lemental
70 . Woo(k EN : Forming partner.. hips w ith employer... PT Magazine of PhYl>ical TIlcrapy 2( I): 56. 1994. . . 7 1. Dinlllny. P: Keeping U1du ~ t ry\ "'ath letes" on the Jo b. PT Magazl1le of Ph y~ l c a l TIlerapy 2( 1):48. 1994. . 72. Lechner. D. e t al : The work -injured pupulallon. In BOI ~sonnauh. WG (ed) : Primary Care for the Physic al Thcrapi\t : Examination and Triage . EI\evicr Saunders. 51. Loui ... 20()~. P 271. . 73. Rie\. E: Working ..olution .. : PTs ,md ergonomIcs. PT Magazl1le of Ph y~ i ca l1l1 e rap y 12(9):38. 2004. 74 . Workplace Ergo nomi c~ Reference Guide: A Publication o f the Computer/ Electronic Accommodations Program. US Department of Defe n ~e. Retrieved October 14. 2005 from http://cap.tricare.osd.mil! acc_sol/Ergonolllics.cfm (www.lricare.osulnt' one ebe 10 change ) the em ironmemaJ conte~ 1. The pa~o n mayor may not lake an in appro priate' amount of time and mayor may not use an a~'>I~tl\e dt:\'lceh) or '.\Id{~). 6 S.a frt~ co n ~i deraliuns-Eilht"r the per~on co mpletes Iht" Jlll\ II ) mdependently \\ Jlh ~ome ri sk to pe r:-.ona l '>il.kl) or \.I.d l-bc lllg or the al"llO lb of ano the r per~on prc.:-..,t:llt lnLiu.. att' that :-.omethlll g about the act ivit y pu:..e ' iJ ha/drd The per ... on mayor may not ta~e an
Modified Dependent The pe rson requ ires a nd receives he lp in the fonn of eithe r superv is ion o r physica l assista nce w ith at least one of the behav ioral compone nt s involved in the activ ity. T he person neverthe less contributes a t least ha lf (50% to 100%) of the total e ffort expe nded to compl e te the activ it y.
5 S upervision or set u p--The person requires and rece ives he lp that onl y invo lves superv ision (e.g" stand ing by. cuein g, coax ing, se tti ng up needed item s or applyi ng orthoses)-i.e., no phys ical contact w ith a he lper occurs during comple ti on of the act ivity. The person contributes a ll ( 100%) o f the e ffort expended to comple te [he ac ti vity, 4 Minimal contact ass istance -The person requi res and rece ives ass istance th at involves phys ical contact w ith a he lper during com ple ti on o f the ac tiv it y. The person contributes nearl y all (75-99%) of the effort expended to comple te the acti vity, 3 Moderate assistance-The person requ ires a nd rece ives he lp that involves physicaJ contact with a helpe r d uring comple tio n of the act ivi ty. T he person still contributes most (5{}-74 %) of the effort expended to complete the activit y.
Dependent The pe rson requ ires and rece ive s help in the fon)) of physical ass istance wi th at least one of [he behaviordl compone nt s invo lved 111 the activity. Either the pe rson co ntributes b, than half (0--l9 cl-) of the effort e.\pended to compl e te the ac tiv ll Y or the activity,,, not complete d .
2 Maxi ma l assislance-Tht: per~on l.~ omribU(es ~ollle (25~9(Yr!) of lhe effort c\pended 10 cOlllpiele tht.' activit)',
o
'l'olal assista nce- The per~on conrribu te~ little or nonr.> (O- 24"1t) of the etlon l'"\pencJ.:d to l'ompletc {h~ itl'tivit} . Acth it,V not ('omp lt'ted- The pl.~r..,on t:uher is unable to com pl e te the aC ll vity even w ith total ib ... i ~ talll:e o r dedlf1C,> 10 pertollll the Jet" II).
Appendix F: The Enviro-FIM™ instrument's decision tree. ~
~
Is the activity completed?
No - =...
ye51
ACTI VITY NOT COMPLETED
Does the person require and receive any help?
I
Yes
+
No
t
Does the person do at least half of the eHort?
I
Yes
+
Does the person do little or non e of the elfort ?
Yes
TOTAL ASSISTANCE
I
No
Does the person take an inapprop riate amount of time, use an assistive device or aid, modify the environment or risk personal safety?
+
Does the person only
N
~ NO ASSISTANCE
. . . Yes receive supervISion or -----. setup assistance?
No
Yes
SUPERVISION OR SETUP
No
MAXIMAL ASSISTANC E
Does the person risk personal safely?
Yes
•
SAFETY CONSIDERATlONS
No Does the person do nearly aU of the effort ?
No
I
Does the person
Yes
+
mOdify the
Yes
envlronment?- -:.:...·· MODIFIED ENVIRONIIENT
No MODERATE ASS ISTANCE
MINIMAL CONTACT ASSISTANCE Does the person use an asslSllve deVice or aid ?
Yes
ASSISTIVE DEVICE
I
No
ADDITIONA L TIME
Appendix G: The Functional Performance Measure's LES™ Eight Levels of Effort and Their Defining Characteristics Len'l \_l;nknuwn : Performa nce o f the task is not
ob'l'i\able. LeH' I O--i\on,,: No effrIT1
I'
c\pc nded e ither be cau~e
la').. perfonnance i:-. not req uired for co mplelion o f the a~~ll\ II~ \0 thl' ob .. er\l'd ,i lualion or bc c a u ~e the task is ,>elf-perfllfm i n,g . Level 6-Bloc ked: The person .... abili t), to perfonn the la .. 1.. I' Ih\\Jnt'J (,l lher
0b . . ef"'ed
"lIu~,\lon
bccau~e c h ara C leri s t i c~
o f the
make attempti ng the tas k fUl ile or
ocrau,e the dCII\ Ir~ !'It' anemrled.
\\':b
aborted before the la"k coul d
Lerel 5-Declined: Thl' opportunity to pe rform th e tas k I\' de-dined. LeH·].+-l mpos,ib le: Th l" ta~k I' nOI comp let ed $uccessfull~
or the la ... " l~ ry
Moderately
Difficult
Barely Oifficult
Neither
Difficult
-3
-2
-1
o
Barely
Easy
\\>ry
Moderately Easy
Easy
+1
Adm inistration Step 1: USing a simplified version to the ORSTM rating scale (below) the patient is asked if the functional task just completed seemed difficu lt, moderate, or easy.
Step 2: Based on the response to Step " the appropriate subseale is selected. In this example , the task was perceIVed as dlfflcult.The patient is then presented with the Difficult Subseale (below) and asked to pOint to the position that identifies ~how diHicult? ~ Three choices are labeled (very di fficult [-3] . moderately difficult [-2) , and barely difficult [-1]), with two choices between the three anchor points : -2 .5 and -1.5.
\\>ry DrfflCul!
I ·3
Moderately Difficult
I -2
Barely DltflCU~
I
-1
A.ddltional Subsc.les · The Moderate Subscale rhow moderate''') responses and scores include : Barety Difficult (-1 ). Neither (0 ). and Barely Easy (+ 1) with two anchor chOICes' , .5 and ..... 5. The Easy Subscale rhow easy?") responses and scores include ' Barely E. sy t+1). Moderately Easy (+2) . and Very Easy (+2.S) with two anchor cholces : ... 1 5 and +2.5
Appendix L: The Environmental Utility Measure'. Acceptability Rating Scale (ARS"
Neither
Barely
Unacceptable
Moderately Unacceptable
Unacceptable
-3
-2
-1
">'Y
o
Acceptable
Moderately Acceptabte
+1
+2
Barely
Administration Step' : Using a simplified version of the AR STM rating scale (below) the patient indicates the acceptability of a functional task using three options: unacceptable, moderate, or acceptable.
UNACCEPTABLE
">'Y
Moderately Unacceptable
Unacceptable
I
I -3
-2
Additional Subseales : Moderate Subseale: Barely Unacceptable ( 1)
choiceS:-.5 and +.5.
Barely UnaotejA ....
I
-1
.
- . Neither (0) , and Barely Acceptable (+ 1), and two anchor
Acceptable Subseale: Barely Acceptable (+ 1), Mode and two anchor choices: + 1.5 and +2 .5. rately Acceptable (+2). and \.i:!ry Acceptable (+3) ,
(From D,lIlford and Slelnfdd , -41>
I> J
w 1'h pemliSSlon) -
Appendix M: Home Survey Form Elevator
Type of Home _ _ __ _ Apartment
Is e levato r prese nt ? _ _ _ Does it land flu sh with
Is e levator avail able '? _ __ Wh at floo r d oes pati ent Jive o n'? _ __ Si ngle fami ly ho me.
_ __ _ _ Two or more fl oors.
noor? _ __ Width of d oor ope ning _ _ _ _ __ __ _ __ Hei ght o f control buttons _ _ _ __ _ _ _ __ C an pati en t use e levator al o ne? _ __ _ _ _ __ _
Does patie nt live o n o nl y o ne fl oor. o r
use all floors of horne? Basemenl. Does pati ent have or use basernent area?
Entra nces to Building or Home Location From Back Side (C ircle one) Whi ch ent rance is used most freq ue ntl y or easil y? _ _ _ _ _ _ _ _ _ _ _ __ _ _ __ Can patient get to entrance? _ _ _ _ _ _ __ __
Srairs Does patient manage outside stairs? _ _ _ _ _ __ Width of stairway _ _ _ _ _ _ _ _ _ _ _ _ __
Number of steps He ight of steps ___ Rai ling present as you go up? R L _ __ Both _ _ _ Is ramp available fo r wheelc hair? _ _ _ _ __ __
Door Can patient unlock. open. close. lock doo r? (Circle fo r yes) If doorsill is presem. give he ight a nd material _ __ _ _ _ _ _ _ _ _ _ _ _ __ Width of doorway _ __ _ _ _ _ _ _ _ _ __ Can palient enter
leave
via door?
Hal/war Width of hall way _ _ _ _ _ __ _ _ _ __ Are any objects obstructi ng the way? _ _ _ _ __
Approach to Apa rtm en t or Li ving Area (Omit if not appl icable) Obstructions? _ _ _ _ _ _ _ __ _ _ _ _ __
Steps Width o f stai rway _ __ _ _ __ _ _ _ _ __ Num ber of steps _ _ _ Height of steps _ __ Railing pre~enl a~ you go up? R L _ __
Ba m _
Is ram p avai lable? _ _ _ _ _ _ _ _ _ _ _ _ __ Door Can p~tient un lock. open , close, lock door? (Circle one) Doo r6l 1l? G ive hei ght _ _ _ materia l _ _ _ _ __ Width of doorw ay Can pati ent enter --~~~:::-I-eav-e----v-ia -d-o-o-r?-.-
Inside Home Note width of ha llways and of door entrances. NoTe presence of doorsills and height. Note ~f patient must climb stairs to reach room . Can patient move from one part of the house to another? Hallways _ _ _ _ _ _ _ _ _ _ _ _ _ __ Bedroom _ __ _ _ _ _ __ _ _ _ _ __ _ Bathroom _ _ _ _ _ _ _ _ _ _ _ _ __ __ Kitc hen _ _ _ __ _ _ _ __ _ _ _ _ _ __ Li vingroom _ _ _ _ _ _ _ __ __ _ _ _ __ Othe rs _ _ __ _ _ __ _ _ _ _ _ __ _ Can patie nt move safely? Loose rugs _ _ _ _ __ _ _ _ __ _ _ _ __ Electrical cord s _ _ _ _ __ __ _ _ _ _ _ __ Fa ulty floor s .--:::_ __ _ _ _ __ __ _ __ Hig hl y waxed floors _ _ _ __ _ _ _ _ _ _ __ Sharp-e dged furniture _ _ _ _ _ _ _ _ __ _ No te areas of particu lar danger for patient. Hot water pipes _ _ _ __ _ _ _ _ _ _ __ _ Radiators _ __ __ _ _ __ __ __ __ _
Bedroom Is li g ht sw itch acce ss ibl e? _ -:--:-_ _ _ __ _ _ __ Can patie nt open and close windows? _ _ _ _ __ _
Bed He ight
Width _ _ _
Bot h sides o f bed access ible? he adboard present ? footboard? _ __ Is bed on whee ls? Is it sta ble? - - Can patient transfe r from whee lchair to bed ? _ __ and bed to wheelc hair? _ __ Is nig ht table wi thin patie nt's reach from bed _ __ Is te lepho ne on i(! _ _ _
Clorhillg Is patie nt 's c loth ing located in bed room ?
- --
Can patie nt ge t clothes fro m d resse r? _ __ c lose t'?
e lse where? _ __
Bathroom
Does patien t use whee lc ha ir _ _ _ wa lker bath room ?
in - - -
DtXs whee lchai r _ _ _ walker _ __ fit inlo bmhroom ?
460
Physical Rehabilitation
. h 'ble? ____ Can pati ent open and Li ght SW ltc acceSS I . close window? - - Wh 3t material are bathroom wall~ tlKlde O~f m the fl oor If tile. how man y inches doe s til e ex te n ro beside the toile t? f the How many inches does til e ex te nd from the top a rim o f the bathtub'! - - Does pati e nt use 101'1el.? _ _ _ _-:-_ _ f Can patie nl transfer independe ntl y to and ro111
--;-:=:-:::----
toi let ? . . Doe~ wheelchair whee l directl y to tOile t lor tran sfers? ___ What is he igh t of toi let seat from fl oor? -.-?---Are there bars or stu rdy supports near toile t .
Is there room ~or grab bars? " . f Can pa t ie nt use slIlk? What IS height 0 sink ? ? Is patient abl e 10 reach and tum off fa uce ts. - - - Is the re knee space beneath sink? - - - - - - - Is pal ie nt able 10 reac h necessary articles? - - - - mirror? e lectri ca l ou tl et? - - - - - - -
Barh;,,!! Does patient take tub bath? shower? - - sponge bath? . If using tub. ca n patient safe ly transfe r wit hout ass istance? _ __ Bars or sturdy supports present beside tub? - - Is eq uipment necessa ry? (tub seat. hands pray auac hment, tub rail. no· skid strips, grab rail s. other _ _ _ _ _ __ _ _ _ _-::-_ __ Can patie nt manage fa ucets and dra in plu g? _ _ __ He ight of tub from n oor to rim _ _ _ _ _ _ __ Is tu b bui lt· in or on legs? _ __ Width of tub fro m the inside _ _ _ _ _ _ _ _ __ If u~es separate showe r stall. can patient tran sfer independently and manage fa ucets? _ _ __ __ If patie nt take s sponge bat h. desc ribe method. _ __
Lh'ing Room A rea Light ~w itch a cce~s ib l e? _ _ _ Can patie nt open a nd c1o ~e window? _ __ Ci111 furniture be rearranged to all ow manipulation of I,', heekhair? _ __ Can patient tran sfer from wheelc hair to and from sturdy c hai r'! _ __ He ight of cha iJ _ __ Can pat ient tran:-.fe r rrom wheelc hair to and from sofa ? _ __ He ight of so fa _ __ Can ambu latory patient tran~fer to and from chair or sofa') _ __ Can patie nt manage televb ion and radi o? _ _ _ _ __
Dining R oom . Li ght sw itch access ible? - ? -bl Is pat ie nt able to use ta e. - - - Height of table - - Kitc he n What is th e table height? _ _ _ Can w heelchair fit unde r? - - -
Can pat ie nt open re frigerator door and take food ? k f od? . t open free zer door and ta eo . _ Can pallen
Sillk
.
?
Can patie nt be seated at s in k . - - Can palie nt reach fauc e ts? T um the m on and o ff' _ _ Can patient reac h bottom of bas in? - - -
She/res and cahillets Can pati e nt open and close? . . Can patie nt reac h d ishes, pots, eattng ute nsils, and food? _ _ _ Comments: _ _ _ _ _ _ _ _ _ __ _ __ __
Transport Can patie nt carry ite ms from one part of kitc hen to another? _ __
Store Can patie nt reach and manipulate controls? - - Manage ove n door? _ __ __ _ __ __ _ _ Place food in oven a nd remove? _ _ __ __ _ . Manage bro ile r door? _ _ __ _ _ __ _ _ _. Put food in and remove? _ _ _ _ _ _ __ _ __
Other AppliQllCes Can patie nt reach and turn on appliances? _ _ __ Can pati e nt use outlets? _ _ _ _ _ _ _ __ _ _.
Coul/ler space: Is the re enough fo r storage and work area? _ _ _ _ _ _ _ _ _ _ _ _ __ _-:-:-. Diagram (incl ude stove. refrigerator. microwave, sink. table. counters. others if applicable) Laundrv If pati en't has no facilities. how will laundry be managed? Location of fac ilities in home or apanment and description of racil iti es present : Can patie nt reach la undry area? _ __ Can patie nt use was hin g machine and dryer? _ Load and e mpty? _ __ Manage doo rs a nd controls? _ __ Can patient use sink? _ __ What is height of s ink? _ __ Able 10 reac h a nd tllrn on faucets? _ __ Knee space beneath s ink ? _ __ Able to reac h necessary a rticles? _ __ Is laund ry Citrt avai lable? _ __ Cnn patie nt hang clothing on line? _ __
Chapter 12 Examination of the Environme nt
Ironing board _ __ Location: _ __ Is it kept ope n? - - If nOI kepI ope n. can patient sel up and take down ironing board ? _ __
Can patient reach outl ct? _ __ Clea ning Can patient remove mop. broom. vac uum , pai l fro m
storage? _________________ Use equi pment ? (mop. broom. vac uum and so
forth) _ _ _ _ _ _ _ _ _ _ _ _ __
Docs patient have numbers fo r neighbors, po lice. fi re and ph ysicia n? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Other Will patient be re-;pon sible for chi ld care ? ___ If so. give number of children and ages: _ _ _ _ _ __
Will patient do own shopping? _ __
Is fam il y member o r fri end avai lable? ___ Is delivery se rvice ava ilable? _ __ Docs family have automobi le? ___
Is famil y member or fri end avai lab le to help wi th lawn care. chang in g high light bulbs, and so fort h? _ __
Emergency
Location of tel ephone in house: _ _ _ _ _ _ _ __ Could pat ient lise fire escape or bac k door in a hurry if alone? _ _ _ _ _ _ _ _ _ _ _ _ __ _ __
461
AppendixN Guidelines for Completing . Essential and Marginal Job Function AnalysIs Form Purpose and Use
eel
th n the respectIve department. 5 WI I d d Ihe physical and cognItive needs of the job. d b b th the tasks performe an It IS a comprehensIve lob descriptIOn escri Ing a . rf m the Essential Fu nctions It maXImizes IntervIew Information to determine the candIdate's ablhty to pe or
• It Qualifies a poSItIOn, describing the purposes and ne
Jt identifies performance evaluation criteria. .. 'l ies ADA mod ification/accommodation . . . t hen a health condItion necessl a It is required for all Job accommodation reques 5 W . d I s'licatio n request if the position is currently vacant It must accompany all new positions that need to be advertised an a ree as I and needs to be advertised.
HelD Table Department: The department where the position is performed . Pos ition/Job Code Title : Merit classification or professional and scientific classification. Job Code: University of Iowa Job Code (EX: GBt l , PC67) . Incumbent : Name of person currently in position or "vacant.~ Position Number: HRIS assigned fkJigit position number (EX: 00000755). Requ isition Number: For advertising . match Requisition Number to Functional Analysis . PoSition Summary : Basic purpose of job and rationale for existence. Function Statements : Action outcome statements, starting with a verb, either essential (primary) or marginal (secondary) to the posltton , Identified by percentange of time performed to add up to 100%. Essential Function : Functions defined by the frequency with which they are performed, the amount of time it takes to perform . . . how the job is impacted if not performed by this position , or whether these functions could be assigned to another position. Marg inal Function : Function that needs to be performed only infrequently, with usually minimal consequence to the mission of the job It performed by another person. Position Context Variables : Needed lor the performance of essential functions. Check "YES" even if only one variable appIaI. this time. Comments : Add anything not already covered that is needed to perform the essential functions of the job, or to further explain context variables
school ....
Cognitive Processes : Level of training needed to perform the essential functions of the position, split between high training and post high school college/technical training. Check MYES~ even if only one variable applies at this time. Bilingual Requ irements : Foreign languages used in the performance of the position . Degree of Push-Pull Activity: DeSignate all forms of push-pull on the job to add up to essential functions.
a total of 100% for performance of . .
Physicat Requ irements : Movements that CANNOT be performed concurrently and reflect the essential functions on pages 1 and 2. PhYSical Requirements : Movement that .cAN be performed concurrently to reflect the essential functions of the job. Vi sion Clarity : With corrected vision to perform the essential functions. Equlp,:"ent, Tools. Electronic Devices and Software: Equipment, tools, electronic devices and software operaled essential fu nctions. '
to peott.....
PhYSical Surroundings and Hazards: Applicable to all areas where esSential functions 01 a position rf d ( tfice ifth Site, lab, hospJtal , kitchen , and so forth ). are pe orme e.g ., 0 • r-
Commen~l : Any that pertain to the physical surroundings or possible hazards Involved in the porto of the posItion. rmance Vehicle Driven : Only If needed to perform the essenMllunctlons (out-ol-town work d I. , e Ivery. and so forth). locltlona: All Job slles where essential functions are performed Day /Hour Schedule : The work shift or shifts if rotating. Hame and Tttle of Supervisor: Name of person to whom this Incumbent reports. Person Completing this Form : Incumbent or supervIsor (Print Or type). SJg"ltur. of Incumbent: Signature of person currently in
~.-- If"
...-,._,.
vacant" or ·new,· teave- b&ank.
01 _
A'.t
I,,. "II _
• C hapter 12 Exam inatio n of the Enviro nment
463
ESSENTIAL AND MARGINAL
T HF UN IVERS ITY OF IOWA l ' ni H' rsit ~ Humlill ReSOllrces Facult) and sian DI',ablht) Sen tcc' 1~llt l1l\c~lt~ SCf\ICC., Butldillg. Ste20 I(lwa C 1\~ . l o\\a 52241- 1911
JOB FUNCTION ANALYSIS
Ta b field-to-field to enter data (or click with mouse). Press the F1 key at any field to see a description of that field . Department : _ _ _ _ _ _ _ __
Position Title: ___ _ _ _ __
Job Code: _ __ _ __ __
Incumbent : _ _ _ _ _ _ _ __
Position #: _ _ _ _ __ _ __
Requisition # :._ _ _ _ _ _ __
POSITIOlf..SUMMARY: Provide a POSition summary. If you need more space, please attach a separate sheet. A position summar y consists of concise, qualitative statements crystallizing the basic purpose of the job and rationale for its existence. FUNCTIOIiSIATEMENTS : AJob functIOn statement shou ld focus on the purpose, the result to be accomplished , and the productivity required rather than the manner in which the function is performed . Begin each statement with a verb. Each statement is to contain one action that produces the desired outcome. Identify whether the functions are essential or marginal (primary or secondary) to the position. Provide the projected percent of ti me to be devoted to each job function during a typical time period.
Essential (Primary) Functions
%
Marginal (Secondary) Functions
%
,.
0.00
1.
0.00
2.
0.00
2.
0.00
3.
0.00
3.
0.00
4.
0.00
4.
0.00
5.
0.00
5.
0.00
6
0.00
6.
0.00
7.
0.00
7.
0.00
8
0.00
6.
0.00
9.
0.00
9.
0.00
10
0.00
10.
0.00
11 .
0.00
11 .
0.00
12
0.00
12.
0.00
13
0.00
13.
0.00
0.00
14.
0.00
"
Essenttal Column Total ··
0 .00%
" Es sential and Marginal Column Totals must 101811 00% .
Marginal Column Tota'"
0 .00°'°
464
Physical Rehabililation
JOB FUNCTION ANALYSIS Page2 POSTION CONTEXl VARIABLES : . .. . rl h r II mary lunctions lor this position. Indicate the responsibitities and aptitudes reqUIred 10 pe orm t e essen la prl Yes No Place an " X" in the appropriate box (or click box with mouse to use as toggle). .J
J
Work With fruslrallng situations: Job objectives are hindered by events beyond the employee's control.
..J
.J
Advise: Counsel others based on legal. financial. sCientific. technical, or other specialized areas; recommend. guide caution . Coordinate : Negotiate. moMor and organize activities of olhers to achieve objectives. but without direct authority.
J
J
J
J
Instruct: Teach others. formally or informally.
J
.J
Group activities . PartiCipate In activities requiring interpersonal skins and cooperation with othe rs.
J
J
Work under time pressure : Rush or urgent time lines.
J
J
Work on an irregular schedule: Unscheduled overti me. called in to work. unanticipated cha nges in work pace.
J
J
Work wilh numerous distractions: Telephone ca lls. visitors. coworkers.
J
J
Handle multiple aSSignments. conflicting demands or priorities.
J
Concentration: Maintain attention to detail over extended period of time , co ntinually aware of variations
J
In changmg situations. J
J
ReacllOn or response: Quick reaction /immedlate response to emergencies of severe consequences.
J
J
Research and analysis: Fact·!inding . Interpretation. investigatIOn in preparing reports or evaluations.
J
:J
Accountability and consequence of error : ResponSible for money. equipment, or personnel. Severe consequences 10 department. University. or coworkers il work objectives are not met.
J
J
Work Independence: Work is performed Independently or with minimal on-site supervision.
J
J
Supervise: Recruit. screen . hire, assign and/or review work. train andlor evaluate other employees.
J
J
Confidentiality: Work with conlidential information. materials. records.
Comments:
COGNII I,{E PROCESSES : Indicate cognitive abilities required 10 complete the essential functions. Yes
No
J
.J
Type an " X'" In the appropriate box (or click box with mouse to use as toggle). Inspect products. objects. or materials. Analyze information or data. Plan sequence of operations or actions . Make deCisions of moderate to substantial effects. with variety of alternatives and moderate to su bstantial consequences. Use logiC to define problems . coHectlnlormation. establish facts draw valid conclusions. interpret information . deal with abstract variables .
.J
Perform baSIC counting. addition . and subtraction of numbers.
J
Perform calculahOns using algebra, geometry, and statistiCS. Comprehend written communication :
J
a. Bastc Instructions. safety rules, office memoranda al high school gradua te level. b Technlc~1 or profeSSional materials. finanCial or legal reports at poSI secondary level. Com pose written co mmunication :
J
a Compose letters or memos uSing standard bUSiness English at high school graduate level b Compose and edit report or technical. profeSSional malenai al post secondary level Verbal comprehensi on : J
J
J
J
J
~
a Complehend simple verbal sente nces and instructions at high school graduate level b Compreher~d technical and compleX' Information at post secondary level Verba l com munlcal ion : a Converse In Standard English at high school graduatt:! level.
b Converse uSing complex technical or prolesSlonat English I Foreign Language Requi rements : a post seCOndary level. J
Comments
465
Chapter 12 Examination of the Environment
JOB FUNCTION ANALYSIS Page 3 DEGREE OF PUSH/PULL ACTIVITY: Indicate the percent of time that pushing and pulling activities are performed. The total should equal 100%.
SEDENTARY
Exert up to 10 Ibs. of force occasionally' and/or a minute amount frequently' ·
LIGHT
Exert up to 20 Ibs. of force occasionally' andlor up to 10 Ibs. of force frequently "
MEDIUM
Exert 20-50 Ibs. of force occasionally' andlor 10-15 Ibs. of force frequently" Exert 50-100 Ibs. of force occasionally ' and/or 25-50 Ibs. of force frequently "
HEAVY
VERY HEAVY Exert 100 Ibs. of force occasionally ' and/or 50 Ibs, of force frequently·' 'Occasionally: activity or condi tio ns exi st up to 1/3 of the time
25·49% 50-74% >75%
NIA
75%
LIFT
To raise or lower an object> 10 Ibs. from one level to another
LIFT
Toraise or lower an object >25 Ibs. from one level to another
0
0
0
0
0
CARRY
To transport an object
0
0
0
0
0
PUSH
To press with steady force. thrust objects forward, downward. outward
0
0
0
0
0
PULL
To drag or tug objects
0
0
0
0
0
BEND
To bend downward and forward by bending the spine at the waist
:J
0
0
0
0
BALAN CE
Exceeding ordinary body equilibrium
0
0
0
0
0
REACH
Extend hands and arms , in any direction
0
0
0
0
0
HANDLE
Seize, hold , turn with hands
0
0
0
0
0
FINGER
PlOch . type, activity with fingers
0
0
0
0
0
REP MOT '
Repetitious movements of arms, hands, wrists , etc.
0
0
0
0
0
T,>tK
Express or exchange ideas verbally
0
0
0
0
0
HEAR
Perceivi ng sound by ear
0
0
0
0
0
SEE "·
Obtain Impressions through the eye
0
0
0
:J
0
"' Check all that appl y:
-,-
'J vision clarity greater than 20 inches
o vision clarity less than 20 inches o ability to distinguish color
--
Repetllive mo\lon
0
C ha pte r J2 Examina tion of the Environment
465
JOB FUNCTION ANALYSIS Page 3 OEGRfE OF PUSH PU Ll, ACTIVITY: ;dicate the percent of lime thaI pushing and pulling activities are performed . The lotal should equal 100%.
N/A SEDENTARY Exert up to , 0 Ibs. of force occasionally' and/or a minute amount frequently" Exert up to 20 Ibs. of force occasionally' and/or up to 10 Ibs. of force frequently" LIGHT
75%
0'""'
0
0 0
0 0
0 0
0 0
0
0
0
0 0
0 0
0 0
MEDIUM
Exert 20-50 Ibs. of force occasionally' and/or 10-15 Ibs. of force frequently"
0
HEAVY
Exert 50-100 Ibs. of force occasionally' and/or 25-50 Ibs. of force frequently "
0 0
0 0
N/A
( A I .md ~ upp lt' mCIll..l r) 1l1l.Ior ..tfC'b , SMA) "111) - h · ' , V ' Ullll:: ott c\.:unnl;" ' l f I ~l l penor L( lllll'Illu.,> <art' ,> hO\~ n . KF = f (; tl t:ul ar 10 1111.11 1011. ( F nlfll Bnx ~ ' I' IW 11C I i. lUll-. \1 I
~,
v..111Ix'n lll \,Mnn.)
/
/
-CORO
- .,REO NUClEUS MEDULLARY RF
_.__.... t _ _+ _ ~~NS()A\'
C hapter 13 Stra tegies to Impro ve Mo to r Fun ction
An early theory of motor control. reflex them)" was established by Shenington :1 His research on se nsol)' receptors led 10 the view th at movement was the res ult of a stimu lusresponse sequence of events or reflex based, Complex movements were nothin g more than the coupling or chaining together of a number of reflexes to produce the final outcome, Thus. sensation assumed a primary ro le in the initiation and production of movement. Limitations in reflex theory abound. II fails to consider that voluntary movemems can be activated in the absence of a sensory stimulus. II also fail s to consider thai ~ome movements occur so fast as to not allow lise of available feedback. FinaUy, it does not consider the infin ite vruiability th at aJlows for different movements in response to the same stimulu s. 2 Hierarchical theory dates back to the work of Hughlings Jackson.4 This theory is based on the assumption that the C S is organi zed into three primary levels of control : high, midd le. and low centers. Contro l was viewed as proceeding in a descend ing direction from higher to lower centers. a "top-down " progression. Reflex theory integrated wit h hierarchical theory presents th e view that reflexes are co mponents of the lower ce nters that became integrated during nomlal maturation and development as hi gher ce nters assumed control. Conversely, reflexes reemerge in contro l of movement when higher centers become damaged. A more current interpretation of this model proposes a theol)' of flexible hierarchies. 5 Within thi s modifi cation. the command hierarchies have been more fully elaborated. The association cortex operates as the hi ghe st level (e laborating perceptions and planning strategies), while the sensorimotor con.ex in association with porti ons of the basal ganglia. brainstem. and cerebellum function as the midd le leve l (converting strateg ies into motor programs and commands). The spinal cord functions at the lowest level, tran slatin g commands into mu scle actions resulting in the execu ti on of movement. Modem hierarchi cal theory proposes that the three levels do not operate in a rigid , top-dow n order as originally desc ribed but rather as a flex ible system in whic h each le\'el can exert control on the others. Shifts in control are dependent on the demands and complexity of the tas k with the higher centers always assumi ng control whenever the task demands are high . SY3fems theory, proposed by Bemstein.6 is based on the view that motor control is the result of the coope rative aClJon~ of many interacting ~ystem:.., working 10 accolll modate the demand, of the spe of mOlar leanling ha ... been described by Fins and Po~nt'rll ~ occuning in relati vely distinct stages. lenlled cogl1J tl ve , i.i!:.,oc iated, and ::wtonomou~. The~e l>lage!-> pro\ide a useful framc\I,o rk for de .. crib ing the leaming procc\ ... .11ld for organIZIng lralllll1g \ traLegie ..... l "Jble 13. 1 prm Ide ... a ~ummaf~
Cognitive Stage
Strategies to Enhance Motor Learning Mo tor learn ing involve :,., a ~ igniti ca nt amount of prac tice and feedbad.. \\'Ith a high level of IIlfonnation pr(X'"es~tng related to comro!. error detection. and correction. MOlOr leaming can be fat' ilitated through the u ~e of effecti\'e l raini ng " trall'g IC\ ( .. ummarizcd in Ta ble 1.) . 1).
Dunng the JOll lal cog nitiH' .,tage uf learn ing . Ihe majo r ubk al h4nd I~ to de\l"lop an o\erall under-;tanding of the
Strategy Development
sl.il l. termed the {ogllI tn (" map or cognllive pl.m. Till') dec l..,ltm ma\...lng rha . . t! 01 " \Ihar to do " rC411lre ... ~I hi gh Je\el til lOgIltU\(, prOtt:'~'Ilng a ~ Ihe learne r perform .. ~ Ut: le"'~l\it' app rm. IIl1,,,,,~
.I_~~
•• ,,,
,..IL,
.,.,; ,~
~. ~
,.
,.
The learner practices movements, continues to refine motor responses, spatial and temporal highly organized, movements are largely errorfree , minimal level of cognitive monitoring ~Ho w
to succeed " decision
.
Assess need for conscious attention, automaticity of movements. Select appropriate feedback . Learner demonstrates appropriate self-evaluation, decision making skills. Provide occasional feedback (KP, KR) when errors evident. Organize practice. Stress consistency of performance in variable environments. variations of tasks (open skills) . High level s of practice (massed practice) are appropriate. Structure environment. • Vary environments to challenge learner. • Ready the learner for home, community, work environments. Focus on competitive aspects of skills as appropriate, e.g., wheelchair sports.
Highly skilled individuals who have been successfull y discharged from rehabi li tation can be ex pen models. Their success in returning to the ' ;real world" will also have a positive effect in mOlivating patients new to rehabilitation. For example. it is very difti cult for a therapi st with fu ll use of muscles to accurately demonstrate appropriate tran sfer skills to an ind ividual with C6 complete tetraplegia. A fomler patient with a simi lar level inj ury can accurately demonstrate how the skill should be perfonned. Demonstration has also been shown to be effective in producing learning even with unskilled patient models. In th is situation, the leamer/patient benefits from the cognitive process ing and problem sol ving used while watching the unskil led mode l attempt to correct errors and arri ve at the des ired movement. l:'. Demonstrations can be live or videotaped. Developing a video library of demonstrations of ski ll ed former patients is a useful strategy to ensure avai lability of effective models. During init ial practice. the therap ist shou ld give clear and concise verbal instructions and not overload the pat ient with excessive or wordy commands. It is imponan t 10 reinforce correct perfonnance and intervene when movement errors become con~ i stent or when safe ty is an issue. T he therapist should /lor attempt to correct all the numerous errOrs that characterize thi s stage bUI rat her allow for some
tri al-and-e rror learning. Feedback . particularly vi sual feed back. is important during early learning . The learner should be directed to watc h the movements closely. The leame r's ini tial perfonnance tri als can also be recorded for late r view ing and analysis. Guidance Guidance invo lves physically assisting the learner during the task. It is effec tive du ring earl y learning in improving performance of an unfa miliar skill by preventing or limiting errors. The therapist's hands can effecti ve ly substitute for mi ssing element s. holding part of a limb stabl e while constrai ni ng unwanted movement s and guiding the patie nt IOward correc t perfoml ance. 13 It also a llows the learner to expe rience the tac til e and kinesthetic inputs inhe rent in task pe rformance, that is, to learn the "sensati ons of moveme nl."l-I T he supporti ve use of ha nds can allay fears and instill confidence while ensuring safe ty. The key 10 success in usin g guided move me nts is to intersperse active prac tice with guided movements, providing onl y as muc h assistance as needed and removing assistance as soon as possible. As manual guida nce is reduced. verbal guidance can be increased. O ve ruse of guided move ment s is likely to rc~u h in depende nce on the the rapist for asshtance. thus
478
Ph)'sical Rehabilitation
becoming a "crutch ." Guidance is most e ffec tive for sl?w postural responses (posit ioni_n g tasks) .and le~s e ffecllve during rapid or ballist ic lasks.1 Once g U1 d~nce IS removed. studies have shown lh at perfomlan ce gain s are not well maint ained o n re temion tests. I.'; Ac1ive Decision Mak ing . As Icaming progresses. the patie nt shoul~ be aC.llve ly involved in se lf-monitoring. ana lys is. and se ll -correction of movement s. The therapi st can prompt the patient in earl y deci sion making by posing key questions. Specifically. the patienl can be asked: • What is the inle nded o utcome of move me nt? What problem s were present during the moveme nt ? \Vhat do vou need to do to correct the pro blems in order 10 achiev; a successful o utcome? • For complex movements. what are the components or ::.teps of the task? How should the components be sequenced?
The therapist should confi nn the accuracy of the patie nt's re sponses. If movement errors are consistent. the patien~'s efforts can be redirected. For example. if the patient consIstently falls to the right while standing, questions can be more direcled (In \I,... hat direction did you fall ? Wh at do you need to do to correct th is problem ?). The therapist can also use augmented cues (i.e .. tapping or li ght resi stance) to ass ist the patient in correcting postural responses. The developmem of deci sion-making skills is critical in ensuri ng continued learning. St rateg)' Refinement Dunm! the assoc iated and autonomous phases of learni ng. the pa~ienr con tinue s to refine movement straleg ies with hig h Ic\ cls of prac tice. Random errors decrease. As conS l ~ le llt e rrors arc identified. soluti ons arc ge nerated. The focu::. i::, on refineme nt of skill ::, and movement consi stency III \aried ellVlronments. Thi s will e nsu re an overall range of moveme nt pa1lems that are adaptable and mat ch the changi ng demands of ope n e nvironmenr\ . The patient's anentlon ~ hould be now focu::.ed on proprioceptive feed bad.. the " fee l of the move me nt." Thu s. the patient i::. direc ted 10 attend 10 the ~e n s alion ~ imrin ::' Ic to the mo\e menl Ihelf and to a;.,~oc iat e Iho\e se nsation s with the motor aC1Jon::. . Guided move ment!) and fa(:ditatioll techniques are counte rprod ucu \C at till ... ;.,tage becauM~ they maintain dependence on the the rapl ::.t and delracl from ;)(.;IIV(' con trol Dunng lat e -::'Iage kaming . the use of di ~ trau er!) .!upport COM UE upper el(uemlly
cenleF 01 mas~ LE
Io..... er e,(uemlly ROM
range of mOl1on
Chapler 13 Sirategies to Improve Motor Function
Recovery RecoverY is the "re -acqui sition of movement skills IOS1 thrOlH!h injury,"2. r ~.1 In complete recovery the perfomlance of the reacquired skill s i ~ identical in every way lO pre in jury performance. It is far more like ly that th e indi vidual 'with eNS insult will demonstrate recovery usi ng preinjury skill" 111::11 are modified in som e way. Compe nsation is
defined a:;. "behavioral substitution , that is. alternative behavioral strategies are adopted 10 compl ete a task,"2. p3!\ For example. the patient recovering fro m stroke learn s to dres~ indepe ndently using th e 1l0naffeClcd uppe r extremity: the patient w ith a compl ete TI leve l spinal cord injury i~ laugh! to roll using upper ex tre mitie s and m omentum . Immediately after in sult . a cascade of eve nt s occ urs. producing a prolonged but reve rsible depressio n of ne uronal acti\'i ty. Changes at a ce llular le vel occur in the immediate area of damaged b rain tiss ue. Di sruption of the blood-brain b3rrier result:-, in edema. w ith an accumulation of intracellular fluid and leakage of blood ce ll s, prote in s, and other IOxic substances that di srupt nerve func ti on. There is a re lea-;e of neurotransmitte rs, g lutam ate, and calci um that acti vate enzymes assoc iated with neuro n death and neuronal degeneration. Free radi ca l damage from toxic particle!'! of oxygen and iron also are assoc iat ed with ce ll death. Denerwuiol1 slIperscllsitil'iry, defined as postsy naptic neuronal hypersens iti vity, resu lt s in decreased synapti c efficiency. Changes also occur in areas re mote from th e injured brain. Blood flow c hange s suggestive o f depressed neural actni ty have been found to ex ist on both sides of th e bram and in both cortical and subcortical structures. areas that are remote from the injured s ite.~() l lljury-relared cortiwl /"corr:ani::alion i ~ ev idenced by a red uc tion in motor corte>. e>'l'I tabilit v of the involved areas. a decrease in the C011H."al repre'icnlati on area of pare ti c muscles. and impairIllen! 01 motor function.~ 7-{>(1 Bram mjur) wa~ for a long time: thought to be penllanent \\ ith lillI e potential for brain repair and rel:ove ry. Thi s i~ no\\ Vlev. ed a" lIlcorrect and can represe nt a dangeroLis wlf-fulfiIl1llf? prophecy when applied to the individual who ::.ufkr'i 1rom weh IIljurie ~. Neuroplaslit:it.v (pla::.! ]c iI Y) ha~ been deli ned a... " llle dbilit) of the brain to c hange and rep,,[ ! 11K ludl:'\ ~ I [[ell1\ 01 ~II -ft'pon (II ann U!>l'); AMAr Arm 1\11I1. llJld I.:u('.rdlll.lllon ); 81 .=. Bilrtlwllude,. I IllC.hUl'e ofh.!.,ic ADL ami d .....!bl l . II) I' (I COI I"lr~ull tndul,;ed Mu\cmt>'l1 ntclup) 11l\l:n\t\'t:. ".lIX" t ~ lil \ I.. -" I'lC,· IIIC prat IICt' 0 1 .:I0ct.:lcJ uppt'r t:~trt:nllly Il E , .... uh r~ ..lndll "l Ollllllhlfkul:'d l E; Enj - t'ku loen,·eph.liogrJph} . EMG .;;;; d('\lIOIlI),ogra ph~ 1:-. .\1 ~' h;II!OOlt,n IMKI lun.. u •• n.tl Ill.igllt'!lC f"~lJrIU' 1I11i1/? IIl}' ; FMA l u,!!1 r..-t\'~e r 1\\~"'lI1enl St·ak ~ ~trl'l..t 'I~llli, lI"lrulllt.>IlI .... !l1l uppt-r e.\,lrelllll) mulur '>t:, lion f. 1 ure piJtielllllloti valion and Sout·· te,>~. MOlor learning Sotraleg ies are u'led to enhance function . incl udmg beha\ ioral Sha l)ing techniqut's that u'>t' reinfon;emenl and reward to prumote ~ l..dl devd opment. Thi i..Ipproach re pre~e nt s. a ~ hilt away trom a Ir..lditional neu· lotherapcut H: tOCUb thai lItdl /e., e>.. h~ n .'> l vt! hand s~on therapy (e.g. , tat iltlated llluVellli: nb) . Wh ile LIlltial move llle nt ~ can be ~si3 l ed or ~ uldcd. acti\ e mme menb are the oVt' wll go..tl.
The therapist serves as coach. providing appropriate feedback and encouraging the patient. Task-oriented trainifIg effectivel y counteracts the effects of immobility and development of indirect impainnents such as muscle weakness or lo~s of tlexibility. It also prevents teamed fU)I1MStof the imoJved '-oegments " hile Sotlmulati ng eNS recoveI)'. ~ 13. 2 prt;':senl ~ a summary of task-oriented training ~
promote function· induceo recovery. Task -on ented tr;lining is not an appropriate for rJiCf): p:\lienl. It::. se ic('{lon is dependent on the degree of~ and sc verit ) o f mOlOr detjctts. Animal studies have ~ ge-.. led that ccd 10 htimu lale , gu ide , u r ass i ~ t movements fo r correct perfo rm ance .
• Ass ist (guide) the patient to successfull y carry out initial movement s as net!ded. • Prov ide augmented ve rbal feedback and verbal reward for small improvements in tas k performance. • Provide mode ling of task performance as needed . • Promote practice of vari able behaviors 10 facil itate adaptation of skill s. StruclUre context-speci fi c practi ce. • Promot e initial practice in a supportive environment. free of distractors. • Progress to v~lfia b l e practice in real-world environments. Maintain foc us on role as trai"ing coach while minimizing hands-on therapy. Continue to monitor recovery closely and document progress using val id and reliable fun ctionru outcome measures. Be cautious about timetables and predictions as recovery may take longer than expected.
Gordon 97 points out the dominant treatment philosophy at the time these approaches were developed was one of musc ular reeducation (e .g .• Kenny method). which could not be eas il y udapted to patients with e NS di sorders. As therapi sts soug ht to develop more appropriate approac hes for thi s group of patients, these approac hes evolved . A central conce pt was the use of sensory inputs to modify the CNS and stimulate motor output. These approaches evolved in a time w hen hi erarc hical theory of motor control was the prevailing mot or conlrol theory during the I 950s and 1960s. Thus the goal o f treatment was initi ally viewed as assi sting the hi gher centers of the CNS in regaining control of motor fun cti on. Acqui s ition o f fun ction was viewed as modeling the acquis it ion of move me nt patte rn:. seen in nonna l deve lopment. Thus a co mmon base was deve lopme ntal activities training (e. g .. pro ne · on· e lbo ws. quadruped. s iuing). Fo ll ow in g remediatio n of impainncnts (e.g .. reduction of to ne and abno rmal re llexcs) treatment progressed 10 functio nal move me nt patte rns. Modifi cati o ns in these approaches have eme rged fro m the chang ing scientific evi dence and theories of mo tor contro l. C urrently there is a much g reate r c mpha ~ i s o n fun ctio nal training. Motor learning .'~ t ra t eg i cs have alway:. ocen a s irong component. Two of the mos t po pul ar appro aches in c urrent use are Nellro(/(' I'e loIHII(' fIIal Treatmellt (NDT) and PtVpr;o('ept;w! Nell nllllll.\nt/ur Facililmioll (PNF). T hese approu('hcs arc not appro priate fo r eve ry patient . Patie nt); w ho de m on ~ tral e ~ ufti c i e nt recove ry and consislent voluntary movcmcllI would no t bene fit from nt:uromuscular
490
Phys ical Rehabilitation
stimu lation and an intensive hands-o il approach. Rather these patients are candidates fo r active task-oriented trai ~ ing. Interveillions o rl!ani zed around a behavioral goal prov ide a bencr vehicle f~r pro mo ti ng continuing functional recovery and lo ng-ternl rete ntio n than interventions that target remediation of a impa innents (e.g .. spasticity). Also. continued use of imcrvemi ons (e.g., g uided movement) may result in the patie nt becom ing dependent on the therapi st, a phenom e non appropri ately labe led the " my therapist syndro me:' For example. a therapi st who is covering fo r another therap ist hears the pati ent remark that he or she is nol helping co rrect ly. It has to be done the way "my therapist" does it. This patie nt b demo nstrating an overreliance 0 11 the therapi st for movement. In summary. these techn iques can provide im portant choices fo r treatment. They can help the patie nt bridge the gap between absent or severely disordered movements and acti ve moveme nts. Once the patie nt deve lo ps in dependen t vo lunt ary control of m ovem ent, the se treatme nt approac hes a re genera lly counterproductive .
Neurodevelopme ntaI Treatment (NOT) is a treatment approach deve loped in the late 1940s and early 1950s by Dr. Kare l Bobath, an Engli sh physic ian. and Berta Bobath . a physiotherapist. IJ .9K The ir work foc used o n patients with neurological dysfu nction (cerebral palsy and stroke). The essential problems of these patiem groups were identi fi ed as a release of abnonnal tone (spalltic iry) and abnomla l postural retlexe~ (pri mitive spinal co rd and bramstem re flexes) from higher ce nter CNS contro l with result ing loss of the nomlal po!:.lUral reflex mec hanism (ri ghting. equilibrium , protective exten~iol1 reactions) and nonnal moveme nts. The role of sen~of) feedback was viewed as cri tical in inhibiting abno nnal reactions and facili tating more nonna l movemenr patterns. Current NOT has reali gned itself with newe r theories of motor control (sy~tems theory and a distributed mode l of eNS comrol) .'N Many different factors are recognized as comnbulmg to loss of motor func tion in patients w ith neurolog lc.d dysfuncti on includi ng the full spec trum o f sen~ ~r) and mOlOr defic it!:. (weak ness.. li mited RO M. im paired lone , and feet) dIrected at .':>upponing bod) M:gmellls and a...!'>i~t Lllg the pallent III adllevlJlg active Lontrol Sen...ory "lI1llUlal lOIl (faclhw,lIon and Ulh,bitlon viu prun.lTli) propnoccpllVe. illld wClI lc mpub) i') u.;,ed during lreJlmelll Pll~lumJ .tllgnlTIt:1lI dnd ~tabJlit) are facilualLxt y,tule e"(.c..:!'>,,,,\l.~ IOn\! and abnonnal Illovemc:nts afe milibued. "or e).amplC' , III the pdllent \\ Ith ,trole, abnonn.iI ohhgato!) ~}nc "g) mo\cm~nts arc reM nc ted y,hile out-ot.'t),nt:rg)
Neurodel 'elopmellfal Ireafm ent (ND T)
movements are fac ihtated. Activities are selected that lit fu nctionally relevant and varied in terms of difficulty and e nviro nme nlaJ context. Com pensato ry training strategies (use of the less involved segments) are avoided. Canyover is promoted through a strong emphas is on patient, family, and careg iver ed ucation. NDT is taught today in recognizQJ training co urses. Appe nd ix A prese nts an overview of NOT principles and techniq ues.
Proprioceptive Neuromuscular Facilitation (PNF) Motor functio n can be improved using Proprioceptivt Neuromllscular Facilitation (PNF). an approach initi>lly developed by Dr. Herman Kabat and Maggie Knott (a physical therapist). loo Synergistic pa tterns of movement were identified as components of no rma l movement. A developmental emphasis was added later by Voss to include practice of various different activities (rolling, prone-on-elbows, quadruped, kneeling. hal f-kneeling, modified plantigrade. standing. and gait). Extrem ity patterns of movement art meational and diagonal in nature (l abeled Diagonal I [01] and Diagonal 2 [D2]) rather than straight plane movemettIS. Coordinatio n with in and between patterns is stressed fa' example, the technique of slow reversals is used to establish smooth linkages between agonist and antagonist actions duro ing reve rsing patterns. Patterns can be unilateral or bilareral and combined with various trunk patterns and posrures. A num ber o f different fac ilitation techniques. largely pr0prioceptive, are utilized to fac il itate m ovement (e.g .. strefCh. res istance, traction, approx imation. and so fonh). ~ manual contacts are used to provide important d.irectiooaI c ues and enhance the function of underlying muscles, "'l' also incorporates a number of important mOlor learning slrategies (e.g .. practice. repet itio n. visual guidance of IJIOYtment. verbal commands. and so forth). It is diJOCtrd • improving func tional perfo nnance and coordinated paae:rrI o f movement and has been used e ffectively to treat paIieaI5 wi th both ne uro muscular o r musculoske le tal deficits. tOl PNf is taug ht today in recognized {raining courses. Appendix B prese nt . . an overv iew of PNF prinCiple and techniques.
Neuro muscula r/ Sensory Stimula tion Techniques
..
A number of therapeutic techn iques can ~ used to facililate , ut tivft te , o r inh ibit mu scle contraction. These ba¥I' Not'n co liN'tively caJl ed fa(.'i lit3tio n tec hniques, aJthoUIi' thl" term is a misno mer. becau.':>t" they also include ... Illques u ~ed for inh ibiti on. The te rlll facilitatioll rdtd to lhe en hanced l:apacny to initiate 3; movement ~ through increas~d neuronaJ ac tiv ity and ahered 5~ potelll lal. An applied st Hnulus m il) lowtr (be 5~ Ihre ~hold of the aJpha molor ne uron but may noI be ~ l' ient to prOliul.·c an ob~eT\ J bl e mo vement ~ Acth ation 011 the other hand refer ... to the actual ~ flon 01 it 1I100'e ment re:-.ponse and 1Il1plic:, reactWII1alil:ftJ thre.':>hold iC'vd tor nt:uronal finng. lobi ...... .......
Chapter 13 Strategies to Improve Motor Function
Ihe decreased capacity 10 initiate c. \\ hereas use of a single stim ulus 1Tl a~ not. Thi ... del11on~trate~ the prope n y of spati al summation \\ ithin the eNS. Rqxated app licat ion of the same still1ulu:-. (e.g.. repealed qUid. :-. tre t c he ~) may also produce the de~lred mOlOr rl''ipolbe 0\\ ing to tempora l sUlllmati on within the eNS. \\ herea..is ting deconditioning.
Muscle Strengthening Stn: ngth training prodllce~ a numbe r of neuromuscuW change!,. There i ~ an increase in the production of mIlilall force due 10 ('hange~ in Ileuml drive (increased recruitment , increased rate, and synch ronization of IiriIa: ~a le) and change~ in mu scle (hypertrophy o f muscle ~ Improved metabo lic/enzY lnatlc adaptat ions, increased ~ and number of myo fibril s, musc le fibe r type adapt.... \Y uh COllvc r,iO Il of ' ype lIB to type IIA). CorUlectivelilillC tensi le strength and bone m ineral dens ity are ~ Body cOInPO~ition i ~ Improved in temlS of body ...... -
motot-
Chapter 13 Strategies to Improve Motor Function of fat to lean. Reaction tim e. func tional perf0 n11ance. and sense o f we ll -being are cle COlllracuon~ (concennic, el·ce ntru.:,
. t . ,) that are used interchangeably during nOlT!!al Isomenl.: movemel1t . Th,·s is a very different focus from the s!raj-" &'" I of motion and isolated movements commonly p anles ed during PRE and isokinetic training. Intrinsic sen -p ~ ... . sory input (somatosensory, vestibular, Visual) IS maximized durina functional training. C;mbining strength training protocols with task-specific practice is an effective strategy to maximize t~ansfer gains to functional skills. For example, strengthenmg of weak lower limb ex tensor muscles can be first achieved uSlng an isokinetic machine that targets both eccentric and concen· tri c contracti ons of th e quadri ceps. This training can effecti ve ly be followed up with repetitive practice of functional activities also demanding similar extensor control (e.g., partial squats. sit-to-stand transfers, and stair climbing). The important consideration here is to match the strength training protocol to the requirements of the funclionallaSk in terms of range of motion achieved and type, magnitude, and speed of conlraction.I O'}
Endurance Training Muscle endurance can be improved with exercise using dynami c contractions of large muscle groups repeated over time. Effects of endurance training are both central (cardiovascu lar) and peripheral (muscular). Peripheral adaptations include improved oxygen delivery to the exercising muscles. improved metabolic exchange. an increase in the number and size of mitochondria. increased myoglobin. and improved enzymatic activity. Essential components of an exerc ise prescription include the following interdependent elements: frequenc y, intensity, time or duration. and type or exe rcise mode (the FlIT equa/ion) along with pr0gression of phys ical activity, III Training modes and equipment include walking and jogging (overground, treadmill pool), 9c1ing (e rgometers ). stepping (steps), or switllllliJl8 (pools). Patients with deficits in motor function may dem0nstrate poor musc ular endurance and fatigue. Faa. . is defined as the inab ilit y to Contract muscle repeatedly over time. Thus exe rcise cannOt be sustained and exercise tolerance i ~ red uced. The onset of fa tigue is variable froID patient to pat ient. Although many differenr factors ma) playa role, among the most imponant are the type - ' inten!o. ity of exe rcise. \Vith the onset of fatigue, patienIS will dcmon" tn.He a dec rement in force production progrcs~ing to toral exha ustion (a ceiling effec t). Fatigue caD arbe from neuromusc ul ar dist"ase affecting three primarY , ilOS: ( I) the eNS (central faJig ue). (2) the peripherBl """"': or neuromu ...cuhu junction, or (3) the muscle ilSClf." ~.1{al11ple~ of condition.'> tbat can produce debilitating fIIiIUI IIldudr multiple bcleros i~ . Guill ail1-Barre syndrolDlo r hrolll l' faugue ~yndrome. and post-polio syndrolllD, rea.1~angl!r of t!\.c rcl:..t' trainmg \\, ith these patients ot IIlJury and O\t'r"ork \\f'akness. deflned as a.,.oI1 ,.,. delTca ...c III absolute Mreng lh and endurance as I retJMlI..tI. C.\{;C~~I \ e aC ll VIl).lu For e:xample. follo..... ing an ~
is"'"1:"
Chapter 13 Strategies to Improve Motor Function session a palienl wilh post-polio syndromc may demon~l r3te prolonged weakness a nd fa tigue that does nol recover with res!. If exerci se is ex hau stive. the patient may be unable to get OUI of bed the neXI day or perfornl non11al ADL. Even a si mple condilioning program shou ld be carefully monitored and progressed slowly 10 avoi d ove rexertiOl; and injur)'.II~-ll1 In general. moderate in tensities of exercises in the range of 60 to 70 percent of maxima l oxy2cn conslIl11plion o r "somewhat hard" Rating s of Perce ived Exertion are recommended wh il e high intensities are contraindicated . A frequency of 3 days/week or a ltcrnalC day s is ideal u',111 ROM C.1J1 be /.Ir 11\'( (A I (i.e .. agoni st cont raction further inhibits the tight muc.;cle via muscle spindle activity). Although the se tec hniques were originally mean t to be app lied wh il e using P"IF patterns, clinicians have also used them in anatomical plane, of motion. Research has demonstrated the effectl\ e ne5~ and superiority of facilitated stretching tec hni ques mer static and balli5 tic l:> lretching tech niques. PI - Uti A n additional be nefi t is that pati ent~ frellue nll y re port less di:,comfort "'ith the appl ication of facilita ted stretching tcc hmques a!'l compared to ot hl.!r stretchin g m ethod ~. Becau se lhe inhibitor) mechanlMn~ affect primarily l1lu!o.cle and depend on \olumary contrac tion. these tec hniques are not elfc::c tl\ e \\Ith very wea l-. or paral yzed mU5c1es or range IlIlll Lation as!'lociatcd wi th \ublttam ial connecti ve;: tl s'>ue c hJ.n ge~ (c hronK contracture) . Freq uency of :-, LretchlOg (numbe r of ~es~ i o n s pe r da y or per week) varies according to underl ying cau~e. the chron lci t) and st:\c rit) of ~on t racture , the p:.tticnt \ age and ICH I of ti~:o:.ue inLegnt) and healillg. and medical
manage me nt (use of corticosteroids), lOS O ptimally mul_ tip le sess io ns per week (i,e .. tw~ to five sessions/week) are balanced with adequate rest III between to minimize li ss ue soreness. Exercises should be followed by active fun cti ona l movement s t h ~t ma,x.imize t~ e mobility gained. Pat ien ts and/or the ir families/ca reg ivers shOUld be taug ht stretc hing exercises (i.e., se lf-s tre tching) as part of the HEP to ma inta in carryover ou tside of the cl ini c setting .
Strategies to Manage Tone Tonal abnorma lities are one of a number of features tharean affect motor fun ction. Muscle tone refers to fimmess of the ti ssue and is the resistance to pass ive elongation or stretch. It is a function of both mec hanical--elastic propenies of muscle and neural drive. The te nn poslural lone refers to the overall level of tension in the body musculature necessary to maintain body posture against gravity. Changes in tone can vary fro m highe r than nonnal tone (hypertonia) to lower than nonnal tone (hypotonia) or fl uctuating tone (dys. tonia). See Chapter 8 for a complete discussion of IOIlaI abnormalities and examination procedures. Patients wi th upper motor ne uron (UMN) syndrome may ex hibit spastic ity. S pasticity is defmed as velocity· dependent hypenonia and hyperactive tendon reflfxes (i ncreased deep te ndon reflexes. DTRs). Additionalposirn. signs assoc iated wi th UMN syndrome include clonus, spasms. mass refl ex responses (exaggerated cutaneous and autonomi c reflexes. fl exor reflex afferents [FRAsJ). aM pathological reflexes (e.g .. Babinski . Hoffman). NtgDlivt signs include muscle weakness. slowness of muscle acm'ltion . abnorma l motor unit recruitment. dyssynergic panems or obligatory synergies. and loss of coordination and dex· te rity. Functionally the patie nt demonstrates poor volitional cont rol of move me nts and limitations in func tional stills. The lim bs are typi call y held in fixed. abnormal postwft wit h antigrav ity muscles primari ly affected. For example. the upper extremity typically a.,.>;sumes an abnormal f1eIOf posture whi le the lower extremity assumes an abnonnll extensor posture . If left untreated . spasticity can lead 10 tht deve lopme nt of ",econdary impaimlents such as C()IltrIClu re. pos tural as) mmelries. and deformity. In conb'lSl. Ihc patient with hypotonia typicaJl y demonstrates loss of_ \\ ith weal.. or paral yzed muscles. joint instability. and dt:fomlity. Follo\\ ing ne urological insult, tone varies re1ative 10 recovery ~ Iage. For e\a mple. the patient with I ~ ~r recem !!I trol-.e or "pinal cord inj ury ",ill present willi" tlal ilacC ldlt) dunng the slage o f cerebral or spinal slttotl. while the :-.umc patient in the po:-.I-3cule stage will oftIII demonstrat e emerg ing :o:.pasllcity. Asymmeoies ol be twee n lI111b~. bet\\een t h~ two s ides of the bodY. ,. bel\\t:e n IlInbs and Ihe trunl are common. AsyJllllWlriel may :11:-.0 occ ur \\ Hhin a limb from muscle 10 muscle- For e"ample. the prOX imal muscles are spCbtic while die ... hand mU'icle:o:. are ilacc ld.
ChapleT U Sfratcgil''i lO Improve Molor Function
497
Str3legie. for Managing Hypertonia
Hig hly slressfu l and effort fu l ac tivities shoul d be mini -
A num ber of in tervent ions can be used to manage spasti c i t ~ . Tht'!:-t' incl ude pf010ngcd icing. pro longed stre ich. inh ibito ry pre s, UJ'c. a nd ne utra l wa mlth. See Appe ndi x C for :1 compkt e d ~ !'o c rip li on of I h e~ e techn iques. Rhythm ic rol:Hioll (RRoJ j, a highl y effecli ve exe rc ise techni que Ihal can lx' u,-cd 10 red uce hype rlo ni c ily 3nd increase ra nge (see .Append; " B), Preci5c hand ling o f a ~ p} prog rc~')lng ll) largt.' r afl. ;:. 0 1 moveme nt Smooth, rel: lprocu l ll1\)\t.' fIle nb are pracllc.:ed .
Pa tie nts and the ir famil y or ca regive rs sho uld be ed ucated abo ut the need to m a intain le ng th of spasti c musc les. Dail y RO M exerc ises are stressed as we ll as e ffecti ve use o f sire tc hing. positi oning, a nd splinting techniques,
Serial Casting Se ria l casts co mbined w ith stretc hing are effec ti ve in red uci ng hype rto ni ci ty. improv ing range, and red uc ing de fofm ity. I-I9- 161 Serial casting is used w he n traditiona l tec hni q ues fa il a nd the pa ti ent is at ri sk fo r developm ent o f contrac tu re s and de fo nnit y, o r de mon strate s ine ffec tive m ove me nt pa ttern s or seve re limitatio ns in hyg ie ne a nd skin ca re. Inh ib ito ry and RO M techniques a re first used to move the lim b into its full y le ng the ned ra nge . Nerve bloc ks call a lso be used to improve ra nge pri o r to castin g.
The cast is then ap plied while the limb is held at the end of ava i labl e range . The sustained positi on produces relaxation of the spasti c mu scl es, thoug ht to be the result of GTO autoge ni c inhibit io n and adaptati on of stretch rece ptors. 161 Ne ulra l warm th and co nt inuo us e ven pressure may also be co ntributing facto rs, Inh ibi tory casting has been fo und to promo te c hanges in m uscle or te ndon leng th and sarcome re di stributi o n. 16J The casts a re Iypicall y c hanged e very 5 to 7 days (se riaJ applic ation ) to g raduall y inc rease avai lable ra nge . Poor casting tec hni ques include lac k o f e ndrange po:,it ioning o f the li mb. loose-fittin g caSI. o r insuffic ient paddin g. Faul ty lec hnique may res ult in a lack of im prove me nt or eve n inc reased lone. skin breakdo wn espec ia ll y o n bo ny pro m ine nces. o r ne rve compre ss io n. An ove rl y rcs tric li ve ,,: as( can res ult in decreased c irc ulation and pc riphc m l edem a. Hi g hly ag itated pa tie nts may pme nti a ll y inj ure the l1l :,cJves and dem onstmte i ncr~a sed risk of :- /.. in breitl...down a nd ('3::. 1 breakage . Pat ie nt s w ith cog nitive or COlllmu nl ca ll o n impairme nt.!l sho ul d be tllOflllOred c lo::.cI ) becau o;,e Ihey \\ ill ~ unable to indicate pa in o r disl:omfo n and pOle lll ia l skin breakdown. Casting is COI1traincilcl'I tc:d til pa tIe nt s \\ Ilh ::.evcre he lero tropic o'\s ilicalio n; rn u!'-J d c n gld ll Y: s l... in condi tio1l:' such as open wo unds, blJ :-. lc r,. or abra ... tull s; im paired c irc ulat ion and ede ma: ulu:ont ro llc:d h) pcn en.., ion; un ... lable intrac ran ial press ure ; p.tlholog h.:al IIl llall1llla tofY conditi o ns such as arthritis or guu!: o r 111 mdi vidua ls al risk fo r l'olllpartment 1>y ndrome
498
Physical Rehabilitation
or nerve imp inge ment. Appli cati o n to ind i v idu~l s wit.h l ong.~wnding contracture.s (longer tlwll 6 10 12 mo nth s) IS also con lraindicatt"d. lI.J.u.:', . Adju stabl e orthoses have a lso been used to prov Ide pa s~ i\e . su ~tain('d "t retc h .."it h the added benefit ~ of easy rCnloval for hyg ie ne and observatio n. These dev Ices usc ,a rotating adju s table dial attached to meta l rods and a fl.ex ,ble ac;\, lic the ml0pla slic base. I 6t>"(o1 The required ~dJl~ SI mcnb ~ rt" easier and les~ time con suming than fabr.1Call~lg an ent ire ly ne\\ serial cas l. Dynamic o rtho ses. pnm~nl y u ~ed o n (' Ihow or knee tl exio n conl ractures. use a s pnngloaded or In drauli c mec hani sm to provide nearl y con sta nt pre~surey,,,'I(>') Repo rted ou tcomes of studi es ,usi ng. t~ese dc\ ice., include redu cti o n of contfacturcs WIth Il1I1lJ1ml l cOJ11p l ication~.
Modalities Neuromuscular electrical stimulat ion (NMES ) has been
u~ed to reduce ~pa~tic ity and improve motor functio n ,170 Applic~Hion~ to the tibiali s anterior muscle o r to th~ ~on,l mon peroneal nerve have been shown to redu ce spasllcl ty III the plant~u1lexor m uscles and ank le clonu s,I1I- 17 1 Elec trical ~ti mulation of foreanl1 muscles has been shown to reduce Oe).Of lOne and posturing of the hand . I74 ,I1:'i S pina l cord stimulators ha"e been utili zed 10 red uce severe fl exor and exten,or ~pa"ms. \\ ith variable results . no Transcutaneous electrical nerve stimulation (TENS) ha s been lIsed to improve motor func tion and reduce lOne in patients w ith UMN syndrome. n •. F? Finally. EM G biofeedback ha~ been lIsed to rdax ~past jc mu sc les by monitoring mu scle ac ti vi ty of durIng: ,,10\\. passi ve st retch. Pati ent s are encouraged 10 decrea"e EMG activi ty during p~L'is i ve or acti ve stre tch, Com·er... el). antagonls t~ 10 the spasti c mu ~cles have al~o been moni tored. with patielll~ encouraged 10 i ncrea~e EMG aCli\it) and mu ... c1e cO l1lracti on.17~·IIIf'
Strate gies for Managing Hypotonia Illlef\CnllOn tcchn14ue:-, 10 in c rea~e lOne for pall e nt ~ \\ ith h> potOJll.':> and al tllnes Jl l~ dlllit.:ult to tliffcrenll •.\It: be t\\ecn the 1\\0 ')I.tte~ Sm..'nglhemng I:"e rtl ::.e~ lhal do nOI ove rl oad the weak, hypn[on i... Illu"de ... arc 1I1dli.ak'J Po... turul in~ li.lbllll } i... a C0l11 111011 prol1ltlll. lnh.: n en I10n ., :-. hoult.ll~ dc ... lgned 10 imprm c pthIUral ... labilit y Jll lurll'tlOnaJ p who denlonstrate impairments in static postural coo· trol 1 i.·an ...deet any of J. number o f weight bar· mg, \ allllgr;l\ uy ) pO . . lurt' . . to de-\t' lop "t.lbJlity conuol (set r:.1ble I ~ \l. Po . . !url''' .Ir(" ... dt:l:ted on the basis of ll1 pati ent ...akt> .md k\d of \..'on t](\1 and lol) variety in tenJ\l III tu nl·llt)llalla . . \..., It i ... IInp0rl.lIlt to rel1lt."mber that SOfIX .Jl'Il\ llli." 111.1\ i,.·,tu:-.c tht' pall~nt dl~(res~ lllUially. ,'{be' IJdltent \\ III iet'l Ihll.'.lh:ncJ \\ hen placed in s iruati005 \\ helt' he ~Ir .,ht' i ... In Jeop.ud) l l f IO~lJlg balan Htlllg O!l timulalioll III th e cuntex t of a meanlllglui. ':>e ll -d ire(;tl;d aClI vi ty in orde r to elic it adapti ve behJ\ 10r"';( 04 I' n Vaned ~e n ...o ry ::. tllllul i are pre~cn l eJ ( laC. IJl e, \C!'sllhul ar-pruprioceplI\ e, and \ i ~ ua i) in orde r to engage higher hram (;C I1lt:r~ fo r (.'cmr..t l proce:,>~JOg of ,>('11SOl) IOfofmduon h l' AppendiX C) . rhe O\t:rall goab .:.Irt: 10 f I j Improve ..,enr,or) dhUlIllJ11.U!on: Ident ili cilll on ot "'pe cili" -.,t llnull (e.~ ,1oth'lpt's. \\clghh , lext ure , Jlulll !xr.., \\I II II: n On ..,l.. 1111. lIlh: lhitle .... ,lIld i()(;.litLutinn nf stimu it Jnu l ~) unprm c pen.t:j)tlon ~dt:'- ll ont all t:nt lOll, and f"· . . pOn\t' tu ~n~r)' HlpU .... with appropriate lI ~e ,-,t in lo flll J lI llll to ge ll erale 'peUfil mowl rc')pulhC'" 1 he k.1.:) element':> .Ift: IIlUit l mooaJ pre~e nt .lt lun 01 \ arll .lh dI11t'f':n1 \ llIilUI, 1.:0111 hll\('d
503
wi th functional task training. Foc us is also on postural trainin g acti vities wi th progress ion 10 more difficult adaptive motor responses. Sensory reeducation has been used successfull y to improve se nsory functi on in patie nt s with periphe ral nerve damage.zo5 Patie nt s w ith stroke-rel ated impairments have al so shown benefits from specific sensory training program s. 2Q6.-1(JR Compone nt s of these programs co ns ist of hav in g th e patient practice se nsory ide ntificati on tasks (numbe rs. lett ers drawn on the hand o r arm), di scrimination tasks (detectin g size, we ight and te xture of objects placed in the hand) , and passive·ass isted drawing us ing a pencil. The tasks are alternated between bo th affecled and unaffected hands. Eac h training sess ion stans a nd ends with a se nsory tas k the patie nt could s uccessfull y master. The training group showed a posi ti ve and s ignifica nt improve me nt in sensory functi o n. 20~ An impo rtant feature o f thi s study was that the subjects we re at least 2 years post-stroke. providing strong ev ide nce th at the effects were due to trainin g and not recovery. Continued pract ice with fun ctionall y rel evant tasks is necessary to m ain ta in the pos itive effec ts of any sensory training program . Importa nt cons ide ratio ns for the therapi st in clude hav ing the patient concentrat e on th e relevant se nsory cues, structurin g the e nvironme nt fo r optimal s uccess. and prov idin g ve rbal and visual c ues. Yekati e l and Gultman 20R sugges t that sensory re training should be considered as a regular co mponent of re habilitati on programs along with motor tra ining following stroke.
Sensory Training Strategies for Balance An impo rtant focus o f balance tra ini ng is utili za tion and int eg ration of appropriate se nso ry system s. ormally th ree sources of input s are utilized to maintain balance: so matose nsory inputs (proprioceptive and tactile inpu ts from the feet and an kl e!'.), visua l inputs, and vestibular input s. 209 Careful exa min ation can ide ntify the patient 's u~e of inputs to maintain b;Jlance (e.g .• Clinical Tes! for Sensory /Ilferactio" and Bahlll('t:' leTS IS!). See C hapter ~ for ;.a Jbc u, s ion of thi s test. Training IS dirCl.' ted tu using var) mg sensory condition s to c halle nge th e patient. For examp le . patit'l1t1ot w ho demo lhtrale ;.I high degree of de pendence on vi,ion 1.:~U1 practice baiam:c task s with eye" open and C') e::. C'lo~ e d , ill reduced lighting , or 11\ ~i t uation s o t illacc urare vision lrlC t ro l~um - l' oated h.. nses o r pri ~m g la ... ~e\). Aitenng the vl~ ual inpu l\ allo\\ s the pa ll \! l1! to , hift rOl'l1:') and rehJlll'e 10 uther ,~nsor) II1pUh, I II thl' l'a..,e 10 intact "'(ll11atlh~ l bOr) and ve::, tibular InpUI'" Pa tie nt .., Cdll pral·tit'c "ar) ing ~ o ll1ato::,t:n~or)' lIlpUb b ) ~ Iulldm g Jnd \\ al "ing on diffen:nt ~urfal· es . from nat . . urt3n· . . l fl oor) to l'umpli.lnt surf.tce::, (low to high CdfPl·t pile .l. to den ,,\;" 1'0.1111. A patirnt \\ho IS baretoo l 01 weafln g thin - ~olcu ..,hl.X·~ i~ lxtlt'r ab le to ~HteOd 10 ')l'lhallon 110m the ft'e l than if \~earing thick-... oleJ shoes. C h..tlknge:.. to thl: \ e ... uhular :'lI ) 'h~ 1ll can ~ Introduced by rcliullng both \ l:.-.lIJI .tnd ~OlllrlIOSc ll .. ()r) IIlpUb through
504
Physical Rehabilitation
sensory confli ct s ituations. For example. the pati e nt prac· ti ces standing on de nse foam wi th the eyes closed. The patient can also be directed to wa lk on foam wi th eyes closed. a cond iti on that req ui res ma ximum use o f vestibu la r inputs. Pa ti e nt s should also practice vary in g e nvironme nt al influences such as wa lking ou tside. pro · gres~ in g from relati vely smoot h terrain (sidewa lks) to uneve n terrain to moving surfaces (escalator. e levator). Repe tition and practi ce are important fa ctors in assisting eNS adaptation. Patients wit h signifi cant se nsory loss will require assis· tance in shiftin g towa rd the intact systems to monilor and adjust balance using compellSafOlY fraining Slrale;:ies. For examp le, th e patient with proprioce ptive losses wi ll need 10 learn 10 shift focus onto the visual syslem for fun ctiona l mobility and balance. Thus, the pat ient with bilate ral amput ati ons learns to rel y heavil y on visual inpu ts for cont rol in standi ng and wa lkin g. If defi cits ex ist in more than one of the major sensory system s. compen· satory shift s are generall y inadequate and balance deficits will be pronounced .~ Thu s, the patient with diabeti c ne uropat hy and retinopathy wi ll be at hi gh ri sk for loss of bal· ance and fa ll s. Compe nsatory training with an assistive device is indicated. Other patients mu st be encouraged to ign ore di storted inform ati on (e.g .. impaired propri ocep· ti on accompanying stroke ) in favor of more accurate sen· sory information (e.g., vision). Augmented feedback can ass ist in training (e. g., verbal commands, li ghHouch fin ger contact. biofeedback cane with audit ory signal s. limb load monitor).
Gait and Locomotion Training Substanti al rehabilit ation effort s are directed toward improving gai t to restore or improve a patient 's fun ctional mobili ty and inde pendence . Walking is frequentl y the number one goa l of patie nts who "want to walk" above all ot her cons iderations. Abi li ty to ambul ate independently is often a :-. ignifi cant fa ctor in detemlining d ischa rge place. me nt:-. (e.g.. re turn to home or extended care faci lity). The ahe rn ale to walking is locomotion using a wheelc hair. To eMabli sh a reali stic pl an of care, the physical therapist mu st accurately analyze the patient 's walk ing abil it y. Comprehensive ga it analys is including gail variables and COlll lllon ga it dev iati ons is di :-.c ussed in Chapte r 10. The fun ctional demands of the patie nt 's home , comm unit y. or worl-.. e nvi ronm ent must be considered in planning sue. (..e~~ful Interve nt ions and in predicting a pa Li ent '~ flllllre ~ t a t u~ .
Ga ll is a compl ex skill that require!\ integra ted fun cti on 01 man) Illteracl lng !.yMems. 8 a~ i c requireme nts for walk.
109 IIld ude (I J e~l ab l i:-.hme nt of a rhythmic :-. teppi ng pal tern, (2) body • Ll lh: Athcll t ...en ... alulIl
Range of Motion: • RUE: elbow ROM 0 10 90°; LUE: elbow ROM 5 10 110° • ilL Es: Within norma l limits except for ankle dors ifl exion bi laterall y of 0 10 15°
Motor Function • Tone: (modified Ashworlh Scale grade s. M-AS) Trunk: Tone in the trunk is wi thin nonnal limi ts except for occasional fl exor s pas ms
RUE and RLE: EXlensor lone. M-AS LUE: Flex or lone. M-AS = 2
=
LLE: Ex te nso r tone. M-AS = I • Refl exes : Exhibits s trong assoc iated reaction s in the LUE and inc reased fl ex o r posturing w ith stressful acti v ities. • Voluntar}' Movements: R UE and RLE: Demonstrates purposeful. full. iso lated motions through avai lab le ROM agai nst g ravi ty. Strength is gross ly F+ in th e RUE and RLE . L UE: No vol untary movement LLE: Moveme nt is purpose ful and in abnonnal synergy: ~ Ire ng th is g ross ly F. Head and Trunk: Movement is funct ional and s trength is g ross ly F. • Coordinatio n: Ex hi bit s moderale to seve re alax ia in the head. (runk . and e:\lrc m il ies. Dem onstrat es J1l0de nHe impa irment in tinger-to- nose and toe- tapping test. • Balance: S ilting: Sta ti c: Poor: rL'quire~ handho ld s upport and mode-rate ::t s~ i :-.tanLe: dc.:.'mo n ~trat es ~ac ral 'i iting wilh posterior Lilt of Ihe pt'lvi o; I)~" utlllic : Poor: unable 10 accept c halll' ngc or m ove\\ ithou l 10 ...... of balance
Standing: Stalic : Poor. reqlllre~ Ill:l\ llllal a~si~ t of t\\ O pt' rl'tons tu ~1:lrld in t h ~ par~lIc1 bar~ Uynalnit.:: Unabk .. unl'tiulla l A(.'livitielructional str.lC cgie~ on motor lo kill leamillg. retention . and tr'Jmft"r. RClo Q 47:788. 1976. 16. Salmon!. A. CI al: KnO\\ledge of re!> uh ~ and motor leaming: A Ttvle\\. and (fItleJ.1 appral!>al. P!»Chol Bull 95:355. 198~ 17. Lee. T. et 31 On IIle role of kno" ledge of re!\ult!> In Iilotor teaming: EJ. plonng the gUIdance h)pothe~i!>" J Mot Bt'hav 22: 19 1. 1990. lIt 8I1odeJ.u. EA. et al' Some effed~ of imroducmg and wlthdrll" mg lno"lcdge 0/ re~ul~ earl) and late m praLlice. J Exp P'»chol 5R:!42 . 1959 Iq Magill . R Augmentl'd feedback III mOlOr !o.kllJ 3cqul .. itlon. In Smger. RN. Hau~nbl.l~ . HA. and Jane ll . eM feds) H,mOOok 01 Sport r '>}chology. cd 1 . Wiley. Ne" Yor" . 200!. p 86 2u \\ msteln. C. et al L~arn lng a panl,d-\\CIght-beanng fill 1ll0\emc:nl l" (m'I~terll") . l'l'rll'pI M'Jt Skll h (l()·';'t5. tl)I<X 2~ \l.1/I~1t:IIl. l .
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Chapte .. 13 Strategies to Improve Moto.. Function =,0. Schlendorf. S: Etl"e(:ts of aging and c-.:erci:-.e on the adult central neryous ~\"l'tem : A literature J1'\'iew. Neurolog) Repon (now JNPT) IS·;:!-'. 191}1. 51. Salthouse. T. and Somberg. B: Isolating the age deficit in speeded pertonnance . J Geronlol 37:S9. )QS2 . 52 . Light. K , and Spirdul'o. W : Effecl.~ of adult aging on the mo\"emen! compk"l;it~ factor of re~ponse programming. J Gerontol 45:107. 1090. 53 . Splrdu~o. W: Phy~lcal fitne~s. aging. and psychomotor ~peed: A reVI(,\\ . J Gerontol 35:8s0. 19~O. 5-1. Shephard. R: Phy ... ical Activity and Aging. ed:!. ASJX'n. Rockville. MD. IQ~7 . 55 . Mom' . J. and McManu~. D: The n('urolog~ of aging : Normal \' e~u~ pathologic changt;'o Genatrics 46:47. 1991. 56. Stein . D. Failow~k~. B. and Will. B: Br.lin Repair. Odord U n]\"eT"lI~ Pr.: ....... New York. 1995. S7. CK·melli. P. Tra\('rsa. R. and Rm, ... ini. P: PO'-i-,troke r.:organlzalion of brain mOlor output 10 the hand : A 2--4 monlh follow-up with focal magnetic trJ.n~craJllal stimulation. Electroen...:eph Clin ~.:urorh~·'IOJ 105:-'38. 1997. 58 . Tra\er'l1h ~ u~-a\:ute ,tTOke Pb ~:. Ther 79:8~ 7. 1999. 68. Miltner, \\. el al: Effects 01 cOlbtruJJlt -1Ilduced mo\ement ther:lp) tm pallenb \\ n h ("hronll mOl or defkit~ :after ~ Iroke: A rt'phcatJon. Stroke 30 51)6. 1m 69 Kunlel. A et al ' Con,lTamt-i nduLcd mo\ emt:nf lherap} tor mot or re(I/H:l"?> III chTOnll ~tfo le p.Jllent' Ar...:h Phy ... I\lcd Rt' habll I\O:o~~
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108. Bandy. W. lind Sanders. B: Therapeutic Exerci se:-Techniques for Interven tion . Lippincott Williams & Wilkins. Phlladclphl.a. 2001. 109. Eng. J: Strength training in individuals with stroke. Ph ystolher C"n 56: 189. 2004. 110. O·Sullivan. S. and Schmi tz. T: Physical Rehabili tation Ll~ratory Manual : Focu~ on Functional Training. FA Davi~. PhiladelphIa, 1999. I I I. Hall. C. and Brody, L: Therapeutic Exercise~Moving To".'ard Function. ed 2. Lippincott Williams & Wilkin~. Phil~ldclphla . 2005. 112. American Collegc of Sport" Medicine: ACSM's GUldclmcs for Exercise Teqing and Prescription. ed 6. Lippincott William" & Wilkins. Philadelphia. 2000. 113. Curti ~. C. and Weir. J : O veryiew of excrl'ise rc"ponses in healthy and impaired state>;. Neurology Report (now JNPT).20:13: 1996. 114 Bennett. R. and Knowlton. G : Overwork we aknes~ m pamaHy denervated ~kl'"letal mu ~c1e. Clin Orthop 12:22. 1958. 115. Dl'an. E: Effect of modified aerobic training on movement energetic~ in polio ~urvivors. On hopedics 14: 1253. !9?1.. . 116. Fillvaw. M. et a1: The effects of long-ternl non-Iatlgumg resistance l.'\e~ I ~(" in ~ ubjccts with post-polio syndrome . OrtllOpedics l·tl25.2.1991. 11 7. Ait\..cn~. S. ct al: Moderate resistance exercise program: Its effects in !'.Iowly prog:rcs~ive neuromuscular di~ease. Arch Phys Med Rehabi! 74:711. 1993. 118. American Colkgc of Sports Medicine: .. lblny for o;pon ~. In : Sander.... B (t'd): Spon ... Ph)sical TherJPY. Appleton & Lange. Nor\\-al\... CT. 1\190, P 201 131. Sad). S. el aJ: Fle>.lbibt) 1r.J.lfilfig: Bal1l"'lic . .'>ICular f Ther 77:1 ~0 . 1997. 155. Singer. B. et al: E,.llu:lIion of seri,ll casting to correct equlnoVW'i deformit} of the ankle after aC4u ired brain IOjury In atMrs. Arch Ph}:- Med Rchahd 8 ~ : 48J . .2003 . 156. Bron~kL B: Senal casting for Ihe neu!o loglcal patient. Amtncln Ph}"'lcal Therap} "",,).\)o.:lat lon, Phy sind DI ..abllities Special 11l11.."re~t Secllon NCI\,lett.:r 18:4.1995 . 157. Z;,blotny. C. d al: S~Tlal casting: Clmical apphcations for !.lit aduh he,ld·tnJur..:d pallen!. J Ht',ld TrJ.uma Rehahll 2:-16, 1987. I'iS Sulhl'MI T. 1.."1..11. Sl."fl.11 ca!'.li n~ to prt'H'fIIl'quinus in (lCutc tr.wmatlc head lllJUI) Ph\,iotlk'r C:trI ~O : 34n , 11.,188. J 59 Slt1gt r, H, SlIIgcr, K . and Alh ...,.lIl. G; 5cnal pla:.tcrmg toC~~ C4 U Ill,11 aru~ uetl1rmlty of th ... ankle 1'... 1101\ In~ acquired brain lPJUfY In Jtiulb: I-I: e\ lev. and dlnKal ..1]lpilc.lIIons. Oi.sabil Rchabil 2J;~.29,
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189 . Damis. C . el al: Relatio nship between standing posture and stabi lity. Phys Ther 78:502. 1998, 190. Wannstedt. F. and Herman, R: Use of augmemed sensory feedback to achieve symmetrical .~Ianding. Phys Ther 58:553. 1978. 191. Hoehennan. S. et al: Plalfonn training and posrural stability in hemiplegia. Arch Phy10 Med Rehabil 65:588. 1984. J 92. Shumway-Cook. A. Anson, D. and Haller. S: Postural sway biofeedbac k: It'> effect on reestablishing stance stability in hemi plegic patients. Arch Phys Med Rehabil 69:395. 1988. 193. Hammon, R. et al: Training effects during repeated therapy sess ions of balance training using visual feedback. Arch Phys Med Rehabil 73:738. 1992. 194. Moore. S. and Woollacolt. M: The use of biofeedback: devices to improve postural stability. Phys Ther Practice 2: I. 1993. 195. Nichols. 0 : Balance retraining after stro ke using force platfonn biofeedback. Phys Ther 77:553.1997. 1%. Kasscr. S, Rosc. D. and Clark. S: Balance training for adults with multiple sc l erosi~: Multiple case studies. Neurol Report (now JNPT) 2305. 1999. \97. Nashner. L. and McCollum . G: The organization of human postural movements: A formal basis and experimental synthesis. Behav Brain Sci 8:135. 1985. 198. Benda, B. ct al: Biomechanical rdationship between center of gravity and center of prc,>surc during standing. rEEE Trans Rehab Eng 2:3. 1994. 199. Winstein. C, el a1: Standing balance training: Effect on balance and locomotion in hemjparetic adults. Arch Phys Med Rehabil 70,755. 1989. 200. Winstein. C: Balance retraining: Does it transfer? In Duncan. P (cd): Balance. American Physical Therapy Association, Alexandria. VA. 1990. P 95. 201. Gapsis, J. el al: Limb IO;ld monitor: Evaluation of a sensory feedback. device for controlling weight-bearing. Arch Phys Med Rehabil 63:38. 1982. 202. Gauthier-Gagnon. C. el al: Augmented sensory feedback in the early training of standing balance of below-knee amputees, Ph y~iother Can 38: 137, 1986. 203. Jeka. J : Light louch contael as a balance aid. Phys Ther 77:476.
1997. 204. Bundy. Ac' Lane. SJ. and Murray. EA: Sensory Integration: Theory and Practice. ed 2. FA Davis. Philadelphia. 2002. 205. Wynn Pany. C. and Saiter, M : Sensory fe -education after median nerve ie:-ions. The Hand 8:250. 1976. 206. Goldman, H: Improvemcnt of double simultaneous srimubtion perceptIon in hc:miplegic patients. Arch Phy!'; Med Rehabi147:681. 1966. 207. Weinberg, S. ~t al' Traming sensory a.... arenes~ and spalill o~ant zalion in people .... ith right bnun damage. Arch Phy .. Med Rehabtl 60'491.1979. 20K Yd...at ld, M. nOli Gunman. E: A controlled tna] of Ihe retraimng of the !o.cn.'ory fUllClJon of rhe hand in r.trole patients. J Neurol Ncuro1)urg PSYl'hiatt) 5b.::!41. 19'-n. 209 N~hner. L: Sen~f)', neuromuscular. and bJome-charucat contnootion~ to hUlllan hal3nce, In Dunca.n. f' (cd): Balaw.'c: American PhYlokall"herJpy As~talion. AI(:"'(andria, VA. 1990, P 5 210. FOt'~berg, H' Spinal locomotor fUI1CIIOfl!o and de'iCendmg ~·()Iltrol. In Sjoluud. G and "JorUunJ . A (1.'£) Br.ul! Stem Comrol of Spul.ll Mt"\.hallJ~m ... EIIot'\ let BJvule(hcaJ Pre,». Nev. York.. 19li2. P 103. 211 HalbuOl. K, et 111: An o\ l"m.:ud harne" and trolky ")'tem for bilLllW(' aoJ "mbulanoo "1):.Cs~n~[ and traming. Arch Ph)"!> Med Rd~t'lil N .!20, I W) ::! I::! Huppurt \CI"\U) 1100r .... aJklOg tn benlipar"tk ~uh~.... h Afl..h Ph}""> Me
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Chapter 13 Strategies IlIdlcmifms: En hance thc rapi!"'!, cont rol of the pat ient 's movem ent s: red uce the rap ist fa ti gue through cffrctive u :-~ of body we ight a nd pos it ion . Ver ba l Com mands (V es) : Verba l command s a ll ow for the use of wcll-timed words and appropria te vocal vo lume to direct the patie nt's movement s. o Preparatory commands ready the pat ient for movemen t (\\ hal to do) and need to be clear and concise. The) are optinwlly accompanied by demonstration and/or guided J1lO\e1l1e nl. o Actioll C(J/l1I11C1l1ds guide the patien t through the movement (\\ he n and how to move). Strong. dynamic action comma nds are used whe n ma xim a l "l1 l11ulation of moveme nt is the goal: soft acti on commands are used when re laxation is the goal. Timing i, critical to coordinate the pati ent's acti ons \\ illl the the rapi:-t"s ve s. re sistance. and Mes. o Correcl/I'c commands provide a ugmen ted feedbac k to help the pati elll modify movements. Il/dlCtuiolls: Verbal stimula ti on to e nha nce stre ngth of ll1u~cle cont raction and guide the syne rgisti c actions in pallcms of movement: ve rbal correcti ons provide augmen ted feedback to enhance motor learnin g. \'ision: Vision is used to guide the pati ent 's moveme nt s, enhance muscle co mractions. and syne rgisti c patterns of movemem. Indica fl om: Enhance init ial motor control a nd motor
leammg. Stretch (STR): The elonga t.ed po~ it i on/length ened range and the stretch reflex are used to fac ilitate muscle contraction. All mu scles in the pan ern are e longated to optimize the effects of stretch . Commands fo r voluntary mmemem are always sync hroni zed with stretch to enhance the response. o Repealed .Hr('(c h can be applied throughout the range to reinforce cOlltraction in weak mu scles that a re fading out. IlIdnQflUflS: Enha nce stre ngth of mu scle contractioll and s) nergl ... tic patte rn s of moveme nt. Ap prox imation (A I' ): Approxima tion (compress ing the Jomt ~ urfaces) J" u ~ed to facilitate extensor/stabi lizing mu ~le contraction and stabilit y: can be applied manuall) . functionally th rough the u ~e of gravit y ac ting on bod) dunng. upnght po\ itions. or mec hanicall y using v.t:ighh or \\oeig.hted ve:')\:) or be lt s. Approx ima tion is applied manual! ) dunng uprigh t. weightbearing posi11011\ and III PNF extemor panerm . I llcI!WtU.J/I.\: We.ion pelul in rcduc lIlg JO int pam . IlIdlt{JfuJlJs : Wei..lJ...nt: ~~. ina hiht y 01 Il exor mu\cle~ 10 funtilOn III moh dillng or anti gravi r) palLt:rn\
10
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515
II. PNF Techniques Reversal of Antagonists: A group of tec hn iques that a ll ow fo r agonist contraction fo ll owed by antagonist contracti on w itho ut pause or re laxati on.
• Dy namic Reversa ls (Slow Reversa ls): Utili zes isotoni c contracti ons of fi rst agon ists, then an tagoni sts performed aga in st resistance. Contract ion of stronger pattern is se lected first w ith prog ression to the weaker patte rn . Th e limb is moved through
full ROM. I ndications: Impaired strength and coord in ation be tween agoni st and antagonis t, lim itati ons in ROM . fa tigue • Stabilizing Reversals: Uti lizes alte rn ating isotonic contrac tions of first agoni sts. the n antagonists against res istance, all ow ing onl y very limited ROM . I ndications: Lmpaired stre ngth , sta bility and balance. coordin ation
• Rhythmic Stabilization (RS): Utilizes altern ating isome tric contracti ons of firs t agonists, then antagonists against re sista nce; no motion is allowed . I ndications: lmpaired strength and coord ination, limi tations in ROM ; impaired stabil ization control and ba lance
Repeated Contractions, RC (Repeated Stretch): Repeated isotonic contrac tions fro m the lengthened range. ind uced by q uic k stretches and e nhanced by resis tance; perfo nned through the range or part of range at a point of weakness. Tec hnique is repeated (i.e .. th ree or fo ur stretc hes) d uring one pattern or unti l contrac tion weakens. I ndications: Im paired strength . initi ation of moveme nt. fati gue. and limitati ons in ac ti ve RO M
Combinat ion of Isotonics (Agonist Reve rsals, AR ): Resisted concentric, contraction of agonist muscles movi.ng through the range is fo llowed by a stabil izing contracti on (holdi ng in the posit ion) and the n eccentric. le ngthe ning contracti on. movi ng slowing back to the stan position: there is no relaxation between the types of contracti ons. Typically used in antigravity activities/assumption of postures (i.e .. bridging. sit-t0stand tran sit ions). I ndications : Weak postura l muscles. inability to eccentrica ll y con trol body weight during movement transition s. poo r dynam ic pos tural con trol Rhylhmk Initia tion (Rl) : Vo luntary rela'(ation followed by pass ive mo veme nt s progress ing to ac tive-ass isted and activc-resl ::.ted mO\emcllIS IIJ finally act.ive movemenb. Verbal t:o mmands Me used to set the 'peed and rhythm o f the movements. Light tracking re, i ~ tance i ~ u::.ed dunn g th e res i ~ tive ph3se 10 fa cilitat e.! movement I ndlcurum.'\: Inab ility to re la,'( , h) pel10nicity l~pas t i('j ty. rt gidity) ; difficlihy initiating 11l0vcm~nt ; motor planIlll1g de fil'lb (apraxia or d) ~pra,'(ia) ; motor leaming deficib . communi t:ation de lkits (aphas ia)
516
Physica l Re h abilitation
Contract-Relax (C R): A rcla:~ ~ pa~ t i c it y in ~ pa~ ti (' mU :::t d e ~ ,
I. J o illt . \ppro \. illwl io n SliulUlu s: Compr(,'>~ lon 01 jo int !'> urfal'es Jo inl rt.'l.C PIOr., prlL nan l) Sidlit: , tyP\! I re~ep· tIX'> , Ha ~ lx)lh ~q!,ln e lHal l~ pin:.l 1 cord ) and , upru'Ieg· Illt'll ta l (eNS highe r (c.:O-~·till l r,u:lI o Ll ): c nhJllct"!) joint av. an: ne~!!o A( IIl'llfe .\
518
Physical Re habilita tio n
Techniques: Manual joint compression Mechani ca l usin g weighted ~ames~ . .vest, or. ~It Elastic tubing with compressIOn of Jomts dunn o movemenT Bouncing while sitting on a Swiss ball . extre mity pa tterns. · PNF extensor Com ments: Used In . I . . pu shing actions. Approximation applied to. t.op of s~ ~~lders or pe VIS ~. upri ght weigh tbearing posl110ns fac l~llI es postura.1 exte sors and stability (e.g., sitting. kne~hn.g , or sta n~l ~g ) . Adnrse Effects: Contraindicated with mflamed Jomts.
5. J o int Trac ti o n Stimul us: Tracti on of joint surfaces Acth'ales joint receptors. poss ibly phasic. type II . Has both segmental (spinal cord) and suprasegmental (eNS hi gher centers) effects. . . Response: Facilitates joint motion: enhances Jomt aware· ne.o;;;s Techniques: Manual di straction Mechanica l: wri st or ankle cuffs Comments: Used in PNF Oexor extremity patterns. pulling actions. . Joint mobilization uses slow, sustained tracllon to improve mobility. relieve muscle spasm. and ~uce pain. Ad\'erse Effects: Contraindicated in hypennobde or unstabl e joi nts.
6. Inhibito ry Pressure Stimu lu s: Deep, maintained pressure applied across the longitudina l axis of tendons: prolonged positionjng in ex treme lengthened range ACTil'Gles muscle receptors (Goi gi tendon organs) and tacti le receptors (pac inian corpuscles), Has both seg. mental (spinal cord) and suprasegmentaJ (eNS higher centers) effects. Response: inhibition. dampens musc le tone. TCt'hniques: Finn. ma intained pre~sure applied manuall y or with po~ iti o n in g. Pressure from prolonged we ightbearing on knees (e.g .. quadruped or knee li ng) dampen ~ extensor tone. Pressure from prolonged we ight bea ring on ex tended arm , wrist, and fingers dampen!> Oexor tone (e.g., !> it ting. mod itied plalll igrade). Pre~sure ove r calcane us dam pens plant,trfl exor tone. Tactile pre~~ure ove r ac upre%ure poi nt s relie ves pllin and da mpens musd e tone. Mechan ical: fi rm o bject ~ (cones) in hand, inhibitory
sphnt~ ur casts (e.g., wri!,t, lower leg).
Comments: Inhib itory e ftecl ~ ca n be enhanced by COm bina tion "nh other reluxa tion techn iques (e.g., deep breath ing tec hni q ue~, SOOt hing env ironme lll ) Ad\'t~rst Effects: Sustained positi oning mu) dampt:n muscle cont raction c:nough to affect functional pe rfonnance" (e.g., difficult y walj..jng after prolonged ~necl ing) ,
II. Exteroceptive Stimulation Technique. l. MalltI:! I Con t:!cts . Ius.. F"rm I , deep pressure of the hands in contact Stlmu with the body . " ,es tactile receptors and muscle propnoceptors Acfn'(I (somatose nsation ). Has both segmental (spinal cord) and suprasegmental . (CNS higher centers) effects."" Can facilitate contractlOn Ln muscle directly espons e· . R under the hands. Provide se nsory awareness, directional cues to movement. Provide security and support to unstable body segments. Comments: Can be used with or without res~stance. Adverse Effects: Contraindicated over spastic muscles, and open wounds.
2. Ligh t Touch Stimulus: A brief. light contact to ski n Activates fast adapt ing tact ile receptors Has both segmenta l (spinal cord) and suprasegmental (CNS hi gher centers) effects. Potential for interaction wi th au tonomic nervous system. sympathetic di vision . Response: Protection and aJening responses: prorecnve withdrawal (flexion and add uction) of stimulated extremity withdrawing away from the stimulus; can also see contralateraJ extension in the lower extremity Increased arousal Discriminative responses: identification of touch stimuli , spatia l di scrimination Techniques: Brief. light stroke of the fingenips Brief Swipe with ice cube Light pinc h Or squeezing or pressure to nail bed Applied to areas of high tactile receptor density (hand s, feet, lips) that are more sensitive to stimulatioll Comments: Low threshold response. accornmodales 13pid1y. Effec ti ve in initially mobilizing patients with low response levels (e.g .. the patient with traumatic tnin inj ury who is minimally respons ive) Can appl y trucking resistance to maintain contractionAdverse Effects: O verstimula tion may produce s~ the tic arousal (re bound effe c ts) with undesirable jig• . or-j1ight responses. ColltrailldiCated for pat ients with generd.lized arousal or uUlonomic instabilir) (e.g. , the patient with traUma tic brain IIlju ry who is ag irated and combative). Brief king :"I hould be u~ed \\ ith caution 00 ftW:C. rOlehead, midJlI1e bac k bcC~IU 'il' of risk of adverse s~ rhl' ti c and urou!>.al cffecLI\.
.1. ~IHillt a in"" TOLI" h Stimulus: Dee p, mainta med touch/pressure ACliI·are.\ tactile reccplor~. Ha~ both segmental (spiIrrIII cord ) and , upras(' to an unexpec tcd \"I 'J ual ~lmlUllI!> Vi..,u,ll propnoccptl on : pH)(:tSse)o inforlllittJun abou l body In .l. p.tu: und ~pat .. 11 re l allon~hlps .
Contri butes to contro l m o to r respo nses : aCljve move. ments, postura l/ to na l adju stme nts. Can contri bute to re laxati o n respo nse. Po tenti a l for e mo ti o na l re spon ses (limbic system) Techniques: Structured appli cati o n o f visual stimuli: presenta ti o n of visua l o bjects: vary colors. size, distance. and o rie ntati o n Movi ng visua l targets Computer progra ms fo r v isua l-pe rceptual training Env ironme nta l: al tered li g hting: Soft lights and coo l co lo rs fo r prom o tio n of relaxation (e.g .. the pat ient with traum atic brain injury and confu sed/ag ita ted response leve ls) Bri g ht lig hts, bri g ht colo rs, a nd repetitive even patte rns for gene ra li zed stimul ati o n o f consciou sness, att enti on. and a le rtness (e.g .. a pa ti e nt w ith traumatic brai n injury with decreased re spo nse levels) Vi sual biofeedback can be used to aid movement control strength of muscle c o ntrac tion. or mu scle relaxation. ' Comments: Visual scann ing ac tiv ities are important for patie nts with hemianops ia and unilateral spatial inatte ntio n. Eli m inatio n of ex traneous visua l stimuli and visual d islrac to rs using a q uie t or c lose d e nvironment may be nece ssary to e nsure pa tie nt atte nlio n and visual per4 ceplio n (e.g., for th e patien t with traumatic brain inj ury in the confused recovery stages). Util ize grad ua l rein troducti o n of d istracting visual stim uli in a variab le o r open e nv ironment as recovery peml its. Ad verse Effects : Avoid sensory overload , irritating stimul i that may ca use agitation . Alte red o r decreased visual perce ption occurs with busy. o pen clinic e nvironme nts: vi sual d istractors or sudden. unex pected visual stimuli disrupt motor performance.
V. Augmented Auditory Stimula tion Techniques Stimu li : Verbal comm ands ( Ves) Va riable sou nds: ruul e. cl uste r be ll s Metronome Audiotape!>: fami liar m usic or vo ice s AudilOry biofe~dbcn m ination: conscious awareness and r.e cogni ti on (if l,ounds, audito ry tracking respoAWS AlertUlg. orien ting rt:'!>pon-;es: stan1e response to a loUd nO I ~
Motor re!>pulhc!>: al' tIV\.' IllOvcnle nt responses. IlO..,tural!tolml J.dJ lI..,t l1lent~ HeiaAalion rC'\llOn,e!> EmOllon.11 re!>Pltn~es (limb ic ~ystem)
-
C hapter 13 Stra tegies to Improve MOlor Function
Techniques: Structured appl ication of auditory stimul i: presentati on of vary ing au di lOry sounds.
With yes: considerat ion of p itch. tone. and leve l. vol-
um e/intensit y is imponant : ada ptation occurs with constant vo lume. Re laxi ng. soft. familiar Ill us ic aids relaxa ti on and red uction of lone. Rhythm ic audi tory ~ tiJ11ul a t io n and brisk music aids movemell t initi ation and the development of tim ing
and rhyt hm of a movemen t seq uence (e.g .. marchi ng music fo r pati ents with Parkinson's di sease). Mus ic aids sociali zation; useful in group classes. Auditory biofeedback can be used to aid movement conlTol. strength of muscle contrac ti on, or muscle relaxation. Comm ents: Precise. dynamic ves are an impOrl anl clemen! of PNF. Positive emotional effec ts occ ur with VCs that are motivating and encouraging. Elimination of extraneous noise and auditory di stractors using a qui et or closed environment may be necessary to ensure pati en! att ent ion and auditory perception (e.g., for the patient with traum atic brain inju ry in the confused recovery stages). Utilize gradual reintroduction of di stracting auditory stimuli in a variable or open environment as recovery permi ts. Adverse Effects: Avoid se nsory overload, irritating stimuli that may cause agitati on. Negative emotional effects occur with YCs th ai express anger and frustration. Altered or decreased audi tory perce ption occ urs with busy. open clinic environments; aud itory distractors or sudden loud noises disrupt mal or pe rfo nnance.
VI. Augmented Olfactory Stimulation Techniques Stimuli : Varying odors that stimul ate th e se nse of smell Pleasant odors: vani lla. pe rfu me. favo rite foods Stimulant odors: ammonia, vinegar Actimles nasal olfactory receptors (fast adapting) to eN I (olfactory) to temporal and frontaJ lobes without s) napsing in tha lam us, hi gher centers. Limbic system: Emotional responses Response: Relaxation re sponses wit h pleasant. fa miliar odor!.: Pleasure, positive mood Reducti on of lOne and hYlk rkinetic movements Alening, orienting, arou!'.al re sponse~ wit h noxiou:, odof'): A lertne~!i. arousal (e.g., afler fain ting) In the minimally con!icious patient (e.g., traumatic brain injury): .er('l~ program concurrently With aduh pauenb II P.. common 10 \\on... on ~\'e rdl lc\eJ... of actl\ lue. cOJll urreml) . The ... pecific IKIi\llIelt and tech~ ni~ue . . ~k'l:ted. a., \I. ell as Ih ~i..JlIence. \I. ill be dClemlll1ed b) the anu\.lp.tted gout... t':M.Jbll ... hed Vt.lln the IOJJ\ Idu.11 pallent Chapler D ~ hould he cOlhuhcd fOI de..,t· nplloll~ 01 the mdl\ldllJll ec hIllYuC'!\ dlld addllionJ.1 t f('alm~nt l)ugge~ ~ lion!'>. The l)re p~r.1I01) O1JI \e4ut."n\ ~ IhJI h.. Uo\l.!, u')C'~ a numb(-r 01 oiClI\ lite::. dnd po..,turt':.. UldudJUg bridging 4uad ruped !'> Jllll1g, l-.ncchng ~lIld hall · bn~ellllg . Inlx.lltl-td planll~Iddt- . and 1111. and dlugonally ,. T)PIl"~IIl~ Ih,~ .... ,11 heglll \'0 Ith hlldlel JJ UF. , uppnrl. prog rl"'''' lIlg III UnJhHl:ral. and thC'1l no ~uppo rl \' eight ... htllln~ UUI JI ...o be eUeul\dy praulcrd with the LIE!) ,>Upfll.lrlCtl on ,\ Ihe l.1py h.iIl pldled direl.:t!y In Ilunl o j thl' patient E.\pIOri.,IIOn 01 lLllIn ~ 01 ..,tabilll ) ( LOS) ,hllll id lx' "ddlt~',>sed b~ pr,tt lI(; lIlg extreme . . ul l"e.tt"h .... ,thout 10 . . Ini; bdlant.:e dnd rdum 10 tht: ... t.11111l1; 1>'):. 1\1011 AUI\c reill..hlllg III all dlfeulon. . follol,l" J. ~1IIl!lg balancmg nJ.l~ be pr,u.:III.xd h} l-lilOpleh.: l) dun !Odtmg UE !.upport The Ub nld) hI.: hdd ..1crv~~ tlit'
527
chest (cradle pos it ion) or allered by move ment into shoulder fl ex ion, abd ucti on. and so forth while main taining trunk balance. Funhe r chall enges may be imposed by movement of the trun.k (forward , ba~k ward . and s ide-to-s ide) withou t UE support ; a progresSIOn can be made to appli cati on o f li ght trackin g res istance to trunk movement s. Balance may be manu all y chall enged at the trunk (perturbations) o r by acti ve movements of the LEs (e.g .. cro~si n g the leg!') . Chang in g the si ttin g surface can al so in crease the cha ll enge (e,g .. s itting o n a d isc or wobb le boa rd ). Additio nal practi ce strategies inc lude engag ing the pati ent in ball oon tapping, th row in g and ca tchin g a ba ll to and fro m vari ous dircc ti ons. or involvement in functiona l acti viti es such as putti ng o n a pair of soc ks. tyi ng shoes. and so fo rth . 4. A vari ety of PNF techn iques can be used in si lting to challenge postural control and stability and to promote di agonal and rotati onal movement s. Exa mpl es incl ude UE D I F. DIE. D2F. D2 E. Chop/ Reverse Cho p. and LiflIReverse Lift. 5. Foot pl acement can be altered by starting with fee t flat on the floo r. then {O no fl oor contact (raised sea ting surface). 6. A progress ion ca n be made to silling o n a moveabl e surface such as a roc ker or equ ilibrium board . roll er. o r small the rapy ball. 7, Si lting push-u ps are an important pre pamlOry activity for transfers and locomotor tra ining with assisti ve devices as we ll as fo r proli cient pos itional changes. Th is activity is acco l11 p li ~hed by plac in g amb at sides. exte ndi ng the elbows, and depressi ng the shoulders to lift the bu ttoc k from the mat. The aC li vit y can be accompl ished ini tinJly wilh bearing we ight on the base of the hands (or a fi.sled hand (0 el im in ate e:\cessive stretcb on the wri st and finge r flexo rs) placed d irectl y on the mat or u~ing. pus h ~up block.s wi th graded increments in height. A mooitkurjoll o f the ..,i lling p u ~h-up is placeme nt of bolh hamt... on one side of the body I II a long !'> Iuing position (sidesitungl, The pat ient then pu~hl.:"s down on both UEs to lift the bu ttock., off the m ..tt. This facilitates IO\\ l,;"r trunl.. rorUlion needed for ga lt a ... \\1.:"11 as 1110\ellle-1ll Iran,ition. . frmn ~Illing 10 quadruped pO . . ili(Hl'" 8. ~ 1 0\l.'Ill~1l1 \\!lhm thi ... po... ture ("'l'llOlmg ) hd~ dm."l'! fun('li onal carry(l\l.:" r In !ran ... fe- r.... ,lmbul:\Ilon, and pv~lllt.lnal ( h,tll gl", and l '3n ~ pr.ll' IIl't'd tn ~)t h iong- ..Uld \ hort... !tllng. Th." ~C!l\Jl) tmohL'~ ... llI lting \H"'ight untO one llip Jru.l then Illm IIlg thl.:" oppo..,itc: hlp tor\\ard u... tng a ~h II.' thnl uc h a~ reaC hin g, ben dll1,g , and turning can al so be utili zed . Th c~e c •.\II be practiced fir", on a stab le ~i l1in g ,> urface with prog re!''lIon to an ull'l lable ~ urface (e.g .. ::' Iuin g 0 11 a thera py ball) to iunilcr promole dy namic baluIll;e control. (. l l /\ ICAI ,\'V1 f. SU-/(}-Mand c/c / lI '/ltt' .\ should he 1J d eUnl ((/f('julh ho\('d ol! {lIitlt 'iplllt'd gOll!\ l or {he IIIJ/l'ldlial pat/l'lIl AI/oIlier 1111/ I/II/X \{J 1I(("-: \ 1,\ lur (he pallem lU ""11\11 ott' hilh hoth Itand~ vI/ U\/lpport MoIll e£' (//\lw fl, Ihe ( lUll I
siHv-.\tand. This invol\'es having !lie pariell! scoot 10 Ihe .fro~1f of the chair, position the feet well/uuln rhl' sealillg SlIIjoel' . lean forward, and push lip i/110 I'ertica/ .'Owudlng using UE sllpport. This is a compen. salOn' trainiflg straregy rhar ejJecfI\'l'ly assists fhe patient
. 'eel') {11m, .•. 10 mol'l' J'rrom
\I'lrli 'rlil' 11/0 \'l'l1Icllf fransition . H owever, some CGlllion is l1'urranred ill selecting this approach. It is Typically not efj'l'cfil 'c ill dneloping rhe for-H'ard weight transfer critical for some paliems (e.g .. stroke). Early alld focused use of this strafe!!.y lIIay limi! dynamic weigh! shifting ability as well as slIhsequemly restrict rhe patiell! to use of only those searing slI1iacl!s Ihat proridf a "push off' option (i.e., lJrm, rl'sts).
Kneeling and Half-Kneeling T he kneeling posi ti on fu rther dec reases the BOS and raises the COM . It provides we ig htbearing at the hips simulating the demands of upr ig ht s tand ing al ignment. This position is part icu larl y use ful for establi s h ing lower trunk and pelvic control and fu rt he r prom o tin g upright balance contro l. The posi tion a lso fac ilitates the LE pattern (initiated durin g bridging) of com b ined hip extension with knee tlexion necessary for am bu latio n . In additio n, kneeling can be used to provide inhi bit ion to the quadriceps muscle and thu s to dampen tone in patie nts w ith s pasticity. Reduction of exfensor tone may be an im portant preparatory activity to standing and walking fo r som e patie nts, 11 is usua ll y easiest to assist the pa tient into a kneeling positi on from a q uad ruped posit io n. Fro m quadruped, the patient moves or "walks" the hand s backward until the knees f urther flex and the pelvis drops toward me heels. The patient will be "sitting" on the heels, From this position the patient may be ass is ted to kneeling by using the
UEs to climb stall bars (wall ladder) while the therapist guides the pe lvis . Another method is for the therapist to assume a hee l-si Uing position directly in front of pati ent. Th e patient 's UEs are s upported on the therapist's sho ulders whil e the therapi st manuall y g uides the pelvis. Seve ral suggested techn iques and activities that can be utili zed during kneeling follow.
me
1. Initi al acrivilies concentrate on assisted assumption '" a~..., isted maintenance of the position. S tabilizing reverall (ahe mat ing isometrics) also can be used to prom.l! lglu ~h illing onl0 lorn.trd I!lob.
529
Figure 14.4 Modified phuHigraJe.
530
Physical Rehabilitation
Initial ass ist-to-positi on activiti es are usuall y easiest from a silting posi tion . The patient is seated directly in fron l of a treatment table or olher stable surface of appropriate height A guarding belt Illay be warranted during early transition s from siuin g to plantigrade positions. The patient is asked (or assisted ) to scoot forv.'ard in the chair. The feet shou ld be well under the seating surf;.lce (COM over the BOS ), and the hands placed forward on the support surface. The palien! shift ~ weight forward and moves into the modified planti grade posture. The therapi st provides the needed level of as!;istance by use of the guarding belt and/or Mes. Several ~ lIgge s t ed act ivities and tec hniques that can be used in this posture follow. I. Initia l activities involve ass isted ass umption and ass isted maint enance of the posture. 2. The pat ient i~ asked to hold in the modili ed plantigrade position. Sta bility can be enhanced by use of man ual approximati on force at both the shoulders and the pelvi s. Stabi li zing reversa ls (altemat ing isometric s) also can be used 10 promote stability in th is position. MC s are al the pelvis. shoulde rs, or both shou lders and pelvi s. l. ROM can be increased and dynamic stab il it y further enhanced by rocking through increment s of range . Rocking ca n be used in multiple d irections (e.g .. forward. backward . diagonally) and is effective in in creasing weighl bearing over one or more ex tre mities. Gu ided we ight shifting is effectively accomplis hed by the therapist standing behind the patient with Mes at the pe lvis. ..L A progress ion can be made to static-dynamic activities. Free ing one UE (e.g .. reaching in different directions) or one LE (c.g .. stepping forward-bac kward , side-stepping) will place increased demand s on the three remaining weig ht bearing limbs and promot e dynamic stabilit y. Body weigh t is then shifted over the dynamic limb while the stati c limb remain s ~ta tionary. Thi s wi ll faci litate pelv ic motion and lateral shifting. Rotation of the lower Irunk al~o can be emphasized du ring staticdynamic LE activities.
Standing InHiall ). the patient ~hould be allowed time to become acclimated. to the upright posture. During init ia l standing, iJ1C rhefapl')l ~hould be ale rt 10 complaint s of nau sea or IJghlheadednes~, which may indicate an Olbet of ol'lhu.\latl( (pfJ.\ rum!) h.IJ){Jlellsiofl caw.,ed by a drop m blood pr('~ ... ure. Thest: :-') mptom~ typically disappear as tol era nce to lilt" upright po~tun;" im prove.., . However. if the- patient ha~ ~~n confined to bed and/or a wheel chair for a prulongl!d pel Iud , lhe~e sylllplom~ may be ~t'w re. In th('se ~ itu ~ltion.') a gradual progft:~.')ion of lilt-tabl e aClivi lie!! and carl: fuIIllOIl lIorlllg ~I vital ~Ign.') ( ~ee Chapter 4) may be warralll ed prior (0 ..,tandlng . U ~e of cOlllplt: ~~ i\e .')tOl; killg ~ or wralh and an al>o,i tion (!lonnal BaS). This is a lte mated w ith ..teppmg back\\ard wi th one leg. shiftin g the weig ht po~ len orl ) ...md relU m ing to the :-.tani ng po~ i t i on . Light track ing re",i.,L.tnce can be applied \d lh MCs a l the pel vi.., (e.g .. "'\0\\ revcf,al s ). Pract ice incl udes ..,(eppin g forward. bac kv.ard. fOf\\ard and back\\ard di agonal ..,hift s. :md fo rward and lateral .. tep-up'. UE muvcmenb can al so be s uperimpo ..cd on the:-.e activ lIies to prOlllote trunk rotat ion (e.g .. reCI procal arm :-.\\ ingJ needl!d lor gail. Thi .. \I..'c tlon prc ..,e nt ed a :-.eric.., of ac tiv it ies and exerc- isc!ol deslgn('d to prepare thl..' patient lor locomotor tra in ing . Table ,-' 1 "u mmariLe\ the IJlcreme ntal !Utll.\ of cO//lrol of the~e attl\ Ill e . . progn:\..,lng !rom 1110n: proximal e lement s ( lower trunk. 1~ I \' i ~J u.. ing a large BOS and low COM to more d islOll seg me nt s (kn~e . ..tnl.. le) that lllcorporate a ~ l1la ll B OS tl nd high COM The preparatory act lvillC.S and exerC1'~e, \\ ill fcljurre Larel ul and appropn at e ",c:quenc ing to mcc t ind Ivid ual pat lcnt need '!!. In ton)lI nctioll \\l ith Ihe:-.e prepm·J to r) ClCIl' !! I.:.." P,U i\: l1h rn a) abo be nciit lrom a COllcum: nt pro-
Modified plan tigrade
Trunk Upper extremities Proximal , intermediate, and distal control of lower extremities
Standing
Trunk Lower extremities
gram o f stre ngtheni ng , Oex ib ility, and coordi nat ion exe rc ises: trJIlsfe r tra in ing w ith c m phas is on s it-Io-s ta nd transitions: and ba la nce trai n ing foc us ing o n both s tatic and d ynamic COrl lTo l. Figure 14.6 presents a s um mary overv iew o f pre paratory ac ti vities and co nc urren t inte rvent io ns fo r locomotor trai nin g . For a m o re d e ta iled description of pre paratory the rapeuti c exerc ise interven tions fo r locomotor trai n ing the reade r is re fe rred to Physical Rehabililmiofl LiI!JO/"(101)' Ma nllal : Foclls 01/ FUI/crional Tra ining."!
Locomotor Training Strategies Th l! d iscu~sio n o f locomo tio n tra ining s trateg ies is divided int o the fo llow ing :-.ecti o ns: ( I ) parall e l b,lr prog ress ion , (2 ) Indoo r 0\ ergro llnd prog ress io n. (3 ) ou tdoor o ve rground prog re!'.!> io n. (4 ) locomo tor traini ng us ing body we igh t s up~ Pl) ["( and a motorized tre adm ill . (5) m e rg round trrun lll g u!> lI1g body \\ e lg ht !)llpport . ~tnd (6) loco mo to r traini ng w ith a~" I !)ti vc dev ices.
5.12
Physical Rehabilitation
EJ - I
Quad,"ped
1- B
-
Kneeling and ~ Half-Kneeling
Modified Plantigrade
Concurrent Interventions
Strengthening , Ftexibility, and Coordination Exercises
~
Transfer Training Sit·la-Stand
Balance Training Static/Dynamic Control
Figure 14.6 Overv iew of preparatory activities and concurrent interventions for locomotor training.
The fo llow ing secti on addresses the parallel bar pro!:!res~ ion . Parall e l bars have a time-honored tradition in ~onve nti onal locomotor training . They provide a reasonably safe and stabl e environment to become acclimated to upright st anding: and allow earl y walking practice on a relatively nonnal indoor floor surface for short di stances . They al so pennit the UEs to assist in maintaining an erect posture. static/d ynamic balance control , and to partially or fu ll y un weight a LE. As a high level of stability is provided by UE support. there is less demand imposed for balance control and the hi ghly coord in ated movements required of Il onnal locomotor rh ythm . Prolonged parallel bar training promo tes compen satory practice and learning of skill s that often transfer poorly to inde pendent overground walk ing a nd use o f an a ss istive device. Owing to the increased we ig ht borne by th e UEs. a forward he ad and trunk posture (l imiting hip exte nsion ROM and loading) is imposed and practi ced . Locomotor speed, sy mme try. and rh yth m (tim ing) are ty pi call y dimini shed and appro priate d ynam ic ba lan ce mechani sms c annot be e ffectivel) pro moted . In additi o n. the amo unt of bod y we ight re lief can not be easi ly mo nit o re d. In recent years, the avai lability of partial bod y we ight ~ uppo rt (BWS ) tra inin g dev ices has dimini shed the ro utine use of paralle l ban, in many fac ilities. BWS trainin g can be used in conjunction wi th treadmill training (IT) or lIsed o n ove rground $ urfa ce~ and Lnvo lves the pati en t do nning a hame~s attached 10 a frame th at supports him o r her in an uprigh t ve rtical posture. Tread m ill trainin g usin g BWS is ad dre~~ed later in thi s (·hapter.
be c hecked. If adju stments are required, the patient should be returned to a sitting position. Prior to beginning locomotor training in the parallel bars, wheelc hair positioning and use o f a guarding belt are impor. tant considerations. The patient's wheelchair should be posi·
tioned at the end of the parallel bars. The brakes should be locked, the footrests placed in an upright position, and Ih< patient's feet on the floor well under the seating stuface
(COM over the BOS). The guarding belt should be f _ securely around the patient 's waist. Guarding belts provide several critical funct ions. They increase the therapist's effectiveness in controll ing o r preventing potential loss ofbaJance; they improve patient safety; they facilitate the therapist's usc of proper body mechanics in untoward ci rcumstanc~ and finall y. they are an important consideration regarding issues of liability. The safety implications of the guarding bd sho uld be explained 10 the patient carefully. Locomo tor training in the paraJIel bars is initiated with patient in structio n and demonstration . First, the entire J'I'& gress ion sho uld be prese nted before breaking it into sequenti al component pan s. This will include instruction and demonstratio n in how to assume a standing position in the parall e l bars. g uarding techniques to be lIsed by the therapi st. the com ponents o f initial sr.mding baJance activities. gait patte m to be used. how to turn in the parallel bars.. and how to retum to a s ilting pos iti o n. Demonstrating thcSt acti vi lie" by as~ u1lli ng the role of rhe patient during verbal explanati ons wi ll fac ilitate ieanling. Each component of the paralle l bar progres~ion sho uld the n be reviewed prior 10 the pa tient's 3l:tual perfOnllJIlCe o f the activity. A sequence o f act i v it ie~ fu r use in the pam lle l bars fo llows.
Parallel Bar Progression Pri or 10 ~tandi ng, IWO important prelim in ary a("Jiv i tie~ md ude fitt ing thl; pati enl v. ith a guarding be lt and adJu ~ t mg the parall e l ba r~ . The ini tial adjll~t me n t or the paraHl"! bar~ I ~ an e~l j ma te ba~ed on tht' patic n t ' ~ he ight. Ideal ly the bar~ ~ho uld be adJu ~ted 10 all ow 20 to 30" of e lhow fl e,-;.ion and ( 0111 1; tu about the leve l uf Iht' great er tfOl' ham er. Con ~i den ng indi vidual v ariation ~ in bod y proport ion-. and arm length . the dbo\\ m ea ~ lI rem e li t i ~ u.. uall ) lllo~ t accurat e. Ontl;' the patIe nt i ~ ~tandi llg , the he igh t (If t h~ bar~ "'dn
Assuming the Standing Position To pre pare for ~ Iand i ng. t h~ patient should be instIUC(ed to n~ove fUf\\ard in tht: chair. T he thl"rapist is positioned d irec tly in fro nt of tht.' pat ie nt. A Illt'thod of guardiOl should be ~e lt'c r~ll t h ~H docs not inte rfere with the patienI"s u~e o t tht' UE\ \\h ile movi ng to ~tanding . Having ft\OYC'CI tllrv. th h and~ freed hom the bdr.,.. ~ J StepPing lorward and bad. ward . Pall~Ol stt: p.') 101"\\lan.J "'lIh one! LI:: clJlI~nor ""eight ~h l ft . and then rd urn!> foot 10 Manmg po:, Hlon (0 mlal BOS); altern ated with stepping
533
backward with o ne LE. posteri or we ight shift. with return o f foo t to starting position. Li ght tracking resistance can be appl ied with MCs at the pel vis to promote rotati on. 4 . S ide-stepping and cross-steppin g. Pati ent turn s 90° from a forward -fac ing po s it ion and pl aces both hands on one paralle l bar; weight shifted over support limb and d ynami c limb side-ste ps. Prog ress io n m ade to c ross-stepping ; weight shifted ove r s upport limb and dynami c limb alt ernate ly pl aced anteri o rl y and posteri o rl y across or be hind the stance limb. 5. Forward prog ress io n. Ambul ati o n in the parall e l bars usin g se lected gait pattern and appropri ate we ightbearin g (e.g" partial. full) .
CLINICAL NOTE : The patielll "hould he illstructed to push dOH'n rather than 10 pull 011 the parallel bars while amhulating. inasmuch as this is the marion that el'entually will he required with all assisth'e del'ice. This will be easier If the patient is instructed to lise a loose or open grip all the hal'S rather than a tight grip ; the loose or open grip facilitate ... correct lise of the parallel bars Gild. ultimately. ,he assisth'e del'ice. 6 . Turning. Once the desired di stance in the parall el bars has been reac hed , th e patient sho uld be instructed to tum toward the stronger s ide. For example. with a nOI1we ig ht bearing left LE. the tum sho uld be toward the ri ght. The patient should be instructed to turn by steppin g in a small circle and not to pi vot on a single extremiry. This technique will carryove r to ambulation o utside [he bars. when pivoting will always be d isco uraged becau se o f the potential loss of balance by movement on a s mall BOS. Guarding can be accomplished two ways. The therapist can rem ain in front o f the patie nt. maintain the same hand posi ti o ns. and tum wi th the patient. Th is wi ll keep the therap ist pos it ioned in fro nt of the patient. A second me thod is not to tum with th e pat ien! but . rather, to g uard from be hind o n the re turn trip . In thi s method hand pl ace ments wi ll change d uring the turn. Hand placement is c hanged grad uall y by firsl p lac ing both hands on Ihe guardi ng be ll as the pa tient ini ti ates the turn . One hand the n rema ins on the posterior aspect of tile be l! and Lhe freed hand is placed '1nterior to. bUI nOl touch ing. the sho ulder on the pi.tli enl 'S w e a ~ er s ide for the retu rn trip toward the chai r. A lthough bo th tec hniques are acceptable. the lan er is probabl y more practica l, cons ide ring the Umited space ~t va il a bl e in the parall el bars. 7. Return to ~em ed po~i t i oJl . \Vhen reachi ng the chair {he patient should agai n tum (L') described above. O nce com plete ly turned , paticllt.'l are typica ll y in!>rructed ( 0 continue bal' ~ i n g lip ullIjl they fee l the seat of the chair on th4! back. o f their legs (thl \ \\ ill require !>ubstitulion wi th visual o r aud itory c lues tur patients \\ iLh ilnpaired sensation). At Ihl ~ po im the patient releases the stronger h:-Uld fro m the parallel bar and I'ea\,'hes bac ~ fo r the wheelchair annresl.
534
I'h )'sical Re habilitation
O nce thi s hand has sec ure ly grasped the ~tnnresl . the patient should be i n~trucl ed to bend fo rward s lighll ~_ rclea:-c the oppo:-. ile hand from the parallel bar and p lace II on Ihe olher anllre:-.1. Kce ping Ihe head and trunk forw ard , the patie nt ge ntly rclum s 10 a seated position.
Indoor Overground Progression T hc sCljuencc o f ilcliv iti es in the slandi ng indoo r o ve r· gro und prog res\ ion typ ica ll y includes wa lk in g fo rwa rd ~lIld hac k ward , re ... isled progress ion , side· ste pping a nd crm.:.·:-. tepping, and sla ir c limbing . MCs arc used to g uide and a ... :-. i:-.I cont ro l o f pe lvic move ment. Vc rbal cue in g is lI ~t'd 10 promo te normal t im ing and locomoto r rh ythm . UE ",u ppo l1lll ay ini tiall y be req ui red (e.g .. hands o n therapi st 's ... hou lders). M C~, verba l cue ing, and UE suppo rt arc pro· gre!)s ivcl y decrea:.cd and then e lim inated .
I . Walki ng forwa rd and back ward . Thi s acti v ity can beg in \\ ith :-.!; nd ing, ste ppi ng in place w ith emphas is o n di ag · onal we ighl s hifts fo rward and backward onl O stance lim h: and pe lvic rOlalion in combinati o n with ad vanci ng the ~\\ ing limb. During fo rward progress ion , MCs at the pe lvi!) can be used to g u ide mo veme nts and faci litate mi :.si ng components. Durin g bac kward progress ion, M C~ can be p laced posteri orl y over the g luteal region to promote hip ex te ns ion as we ight is acce pted o nto the stance limb. Thi s act ivity co mbines hip ex tension w ith knee fl ex io n and b particul arl y useful fo r patie lll s wi th hemipl eg ia wit h sy nergy influence in the LEs. 2. Resi::,ted progress ion . Walking forward and bac kward is init iated actively and progressed to application of res ist· ance through MCs at the pe lvis. During forward progres· sion. the Iherapi ::,t may be siand ing o r sitt ing on a ro lling 51001 with bi lateral MCs on the pe lvis. Li ght track ing re .. istance i!) used initiall y 10 promote liming o f pe lvic moveme nts. Approx imation can be used to enhance s ta· bili t ~ of the stance li m b and light phasic stre ich can be u::,ed to faci litale pe lvic rot ation on Ihe swing limb. Re"is.tance can ab o be applied us ing Theraband® arou nd the peh i~ ~lI1d he ld from behind by the therapist. Wands held :-.im ulianeously by the patient and therapi~1 can be u!:>ed to promo te reci procal UE movements and prov ide the patien t ::,omt' ::'Iabi lit y. 3. Side·::,tepping and cross·::'ll.!pping. S ide·~ teppi ng invol vc~ abd uction o f the lead in g dynamic limb wilh fOOl placement lollowc:d b} moveme nt o f the remai ning limb to a parallel po'>l tion wi th the fi r~ t (s.ymmetrical stallC!!). Empha~ i :-. .. hou ld be pl aced on kee ping Ihe pe lvi... leve l. C ro!>s. ::,tC:PPl.l1g imoh ~s .. i ele~"'l eppill g and then cros"ing the rtmalllJng limb up and over the olher limb. MO\·emenb. C,Ul be gUided and facil itated wilh Me!) at the pel v l~. A pro. gre~Mon can then be made 10 application o f re!>i!tralllt .l. J.nu can IIldudl.: c ro~ "' lII g ,u a ... topltght . ~tepplOg un dnd nft it 1ll0\ mg . . . .i1 J.. .... J) . ...... aU.lng unto an cit."\J.tor. and "'JIJ..JIlg th ruugh .1 I'l"volvillg door. ~. Orx:n e.m Ironment Watl..mg . , hould ~ pr.iclh,.ed III it \JrtJblt:. l)l"k:n \,.olllmuill t) envlrunmen t ~ uch a.-, a shop+ plOg mJII (;ommuillty cc:lltel. grOl.cf) .. «Ire. ur other P -I he mlloodie for liS u~ h 1'IupporteJ b) o.ll1unaJ ,rudie, of 1..11, '" Ilh th,>rJtll.' !'oplIlal ('(\fd ieMQlh th.ll reg..umd tnnJ lilllh !>.tcppmg jhll1COb wh~n \Uppork'uIoIDO training was both fIIIiI1It and weK·toIeralld.
Chapter 14 Locomotor Training
539
Evidence Summary Box 14.3 Locomotor Training
(~n'inued)
Subjects/ Design
Reference
Purpose
Hesse. 5, et al ' 1999
To compare the gait of subjects wi1h hemiplegia during locomotor training using body weight support and a motorized treadmill (BWSTT) and overground wal~ng
, 8 subjects with hemiplegia: mean age 59.9 years. Mean lime since onset was 5.7 months. TM walk· ing was done with FWB, 15%, and 30".. BWS. Velocity was kept constant during all trials and was sen-selected by each subject. Floor walklng occurred at a selfselected velocity 00 a 15-m walkway at a mean velocity of .33 mls. Gart analys~ was done tor all oonditions. Velocity, cadenoe. and cycle, stance, swing and double support durations were recorded (average of 10 cycles). GRF at heel and toe ott and EMG activity tor antenor ijl>alis, medial gastrocnemius, biceps femoris, vastus lateral~ , gluteus medius, and
erector spinae on the affected side and tor the antenor bbial~ and medial gastroc on the nonaHected side were recorded.
Prota" EJ. et a~ 200t
To determine rt locomotor tramlng uSlOg body weight support and a motonzed treadmill (BWSTT) WlR Improve galt (speed, endurance. walking status, asslstive devICe use, orthotJc use) and reduce the O"lgen oosts 01 walking
.. ,J,. JiH ');.Jliu"oll, 1i,1t
~'h p.uc.d t-)
Repeated measures i"lot study. 3 men with chronic, Incomplete. thoracic SCls. Three scales to examine galt (1) Garrett scale of walkIng: (2) a...stlVe devrc:e usage scale: (3) orthobc device usage scale. Gart speed measured u~ng a .med ;.m walk, endurance by the distance walked In a 5·minute penod. 0, oonsumptron, minute venlilation, and resplllpcn.,alO ry ,t r.llcg ll!'" (c g .. lIppCI tllllb ",uppon ) Iu '-OJllpe lh~lIl: lor 100\cr IlIllh 11llp.lirllll"111 '111..' n.~i.hlll'd 'I Pcnphe lal ~t! lhor~ Inpu t i~ Cnh3 111..i.'d ItJ j\fOIlHlil..' 111U ,dc ot the floor real"llon torce produred by the atkcled fool. They noted thai Ih(' ledUl:tl~ns In vellICalllour reaction pea~, were prnhahl) due 10 ..t !\hlltmg 01 body weigh t to\\·"ro the l·:.ane. \\ hu.; h '\ a~ a l()f1tnbullllg tractor If] f\!ducing L.ontJ.(" t lo f\...(' at the ai1 eded hip. Neumann q JULInd that COnlrahlll'r'dl use 1,)1 d. ('mll' reduced \I,
the average hip abd uctor muscle EMG activity to 3 1 perctnt be low that ge nerated w hen not using a cane. Researc h s ugge sts that use of a cane is an effective method of reducing force s acting at the rup.34.J6 This coocept is partic ularl y important fo r activities such as stair climbing, when the forces generated at the hip are signifi· cantl y increased.J5 Clearl y, use of a cane has important implications for hip involvement s uch as joint replacements or dege ne rative joint disease. In addition to altering the forces on the affected extremity. ca nes are :-.e lected on the basis o f their ability 10 improve ga it by providing inc reased dynamic stability and. improv ing balance. This is ac hi eved by the increased 80S provided by the additional point(s) of floor contact. The kvel of stability provided by canes is on a continuum The g reat e~t s tability is provided bv the broad -based canes and the least by a ~t and ard c ane-. The following seclion presenti severa l or (he more coml11on types of canes in clinical use and Identifies their advan tages and disadvantages..
Standa rd Cane Thi 'i JS"h'lvc dl?\'ice abo i" rererr~d 10 as a regular or con\'l·l1tI OI1.1I Ci.ln~ tFi~. 1-l. 13A). It is made of aJuminum. \\ood or plJstic ,mel 11l: dard
('fut (' h l'~
546
Physical Rehabilitation
Figure 14.20 Pu.,h-bulton handgri p adju stment with reinfOfCing clip-lock.
A
c
B
Disutil'Ul1taf?es. Because of the tripod siance required 10 use cnllches and the re~u hant large BOS. crutches are awkward in small areas. For the same reason, the safety of tbe user may be compromised when ambulating in crowded
Figure 14.19 \A) Ax Jl l J. ~ cnnch. (8 ) ortho crutch, and 3 lei forearm cnnch.
Incorporate... a pu ~ h - bu l1 on pin mechanism fo r h~ ig ht adj u!'.> tmelll . . ~ lIlli lar to tho-.e found 011 alum inulll cane .... Some alumlOum crutche'l abo h:lve pJ tient he ig ht marl..."", adj.lce nt 10 the notche'l to a ...sist 10 adjustment. The height 0 1 the hand gnp~ fur \\ODden and "orne alummlUlI crutI.-hlln} tUllf I'h)\ /I.k hl\ Junlilun.d .lIl1hul.llulfl \\ tth Inlfllled ~\l·I~' hl lx..tnn!! '1hI..") ..tIl,.' l',I'11\ ,hI IU ... ,... d. IHt·XI.k:lhl\ t' \\ h t'll ... I..tll L hmblllt!
m.tdl· 01 wl,\XI. ,Hid \ ~II l~' u...td
11.11
areas. Another disad\anlage is the tendency of some patients to lean on the axi ll ary bar. This causes pressure at the mdi al groove ( . . pir.lI groove) of the humerus, creating a ... ituafion of potenti al damage 10 merJ.diai nerve as weU a:.. 10 'I(lj.lcent V~l~cll iar structures in the a'(iIIa.
Platform Attachments nl~"t' Jlla(' h m~ nl~
( Fi g. J-L! I ) are abo referred 10 as/ ontrough\. Although Ihey are described bere. thl') .I bn 'lI'I..· u... .:d with \\ : nr
Collt' ... IrJduro:). T he fo rearm pitcc i~ u3ually padded. dO\\ d lll' 11.llldgflp.• tnJ ho.l .. Ve- kro@ straps (0 rIWDt.-1Il th ..: PO'IIIOIl 0 1 Iht' fl'tfI."Jm\ PI .Uroml CnJ h.' he.s art also Ii ... .
h.l .. ~l
LOIl1llkrLI.III)
d\
;HI.ll:lle
fun:d trom iJ poi nt approximately :2 in . be lov. the 3.\ 111:.1 The \\ Id th of I V.O ti nger.\. is ofte n u-:.ed to Jppro.\ lmate Ihl~ dhtance. During mea~u re menL the dl~ l ..d end of the c.:ru tch s.hould be re~ting at a JX.llnt :! In. litleral and 6 Ill. amen or to th~ fool. A general e,tllllate 01 uutch heig ht can be obtamed pnur tu ~ Iandlllg by ... ublraclin g 16 in from the palien(!l heigh t With the -:. houlder~ reht>.ed, the
I . During axillary crutc h use. body weight should always
be borne on the hands and not on the axillary bar. This w ill prevent pressure on both the vascular and nervous
structures located in th e axillary region. 2. 8.dance will be optim al by always maintaining a wide (tripod) 80S. Even when in a resting stance. the patient should be instructed to keep the crutches at least 4 in. (10 em) to the front and to the side of each fool. The foot should not be allowed to achieve paraJlel alignment with the crutches. This will jeopardize anterior- posterior stability by decreasing the BOS. 3. When using standard crutches, the axillary bars should be held close to the chest wall to provide improved lat eral stability. 4 . The patient should also be cau tioned about tile importance of holding the head up and maintaining good postural alignment during ambulation. 5. Turning !> hould be accomp lished by stepping in a small circle rather than pi volint!.
Three·Puint Ga it In Ihi ~ type of gail three points of support coma tthe tloor. It is u ~ed when a non· . . . eightbearing statu!> is required on one LE. Body weight is borne on the crutches in!)lead of on the affec ted LE. The seq ll~nce of rhls gait pancm is illustrated ill Figure l4.12.
Partial \\'eightbearing Gait Thi ::. g dil i!> a 1l\exi.i lkalion of Lhe three-poilU pattern. During fon'vanJ progression of the IIl\tng a railing. bot h cl'lJl che:-.. are pl aced toge ther under onl: ann . Seco nd. the patient sho ul d be ca ut ioned that tht ... tronger LE al",a)" lead~ going up the ~t a ir~, ;'lIld the v,t'al..t:r or IIlvolved limb a.l v.a)~ l ead~ comin g down t "lip 11/11/ the good lIIId dOh 'lI 1\ Ifll fl/e l>ad"). The progrC'l"Jon \ 01 ')talr c limb lll g tcc hniq ut: .. are pre\(nted 111 Bu\ l . tS. The fo lk)wing gUounding when the heel makes contact with the noor can provide immed iate feedbac k on foot placeme nt. Similar dcv il:es can also be attached to a canc (often refe rred to [I S a hio/c('(Jhack cOl/e). The principle of ope ration is the same and incorporates a SIr-tin gauge. Auditory ~ig n a l s provide the pntient with infonnation on piuppon : A Neurophysiologically sound approach whose time has come for randomized clinical trials. Neurorehabi l Neural Repa ir 13(3): 157. 1999. Barbeau. H, Fung, J. and Villolntln : New approach to retrain gait in stro ~ e and 'pmal cord mjured loubJecb . Neurorehabil Neuml Repair
Ilml77. 1999. 13. Barbeau. H. t'l al: WalkUlg after spinal cord injury : Evaluation, treatment. and func tional recovery. Arch Phys Med Rehabil
SOt:!r:!:!5, 1999 14 Self-I\draghl. A li , and Hennan, RM ' A no\el method for locomotion ltammg J Heild Tmuma Rehabil l4(2) :146. 1999. IS. Fldd-Fote, EC: Splilal cord control of movement: ImphcatlOns for 1Or..:(lml)lor rehatnlnallo n fo J1o wlIIg !>plllal cord inJury. Ph y~ Ther bh:5':477, ~OOO. 16. Fm.:h . L and Barbeau. H Hem ipleg ic gail : Ne .... lreatment strategle, PhY~lvr:he r Can 38(1,:16, 1986. 17 Pillar_ T. Dl tl..~tein. R. and Smo hmki . Z: Wan.. ng reeducation WIth partIal rellel of bc:.;d) .... e lght In rehabilitatIon o f palle nI.') WIth loco nWlor d"ablltut.'!.. J Rehab.1 Re!o De\' 28(4): 47. 1991 18 VI'lnlJn. M . .and Barbeau, H' The effects o f body weight ,uppon on the klo..omolor pattern of !>pa\lIc paretic patlcnts. Can J Ne urol Sci !tdl~ . IWIt.) 19 Wt:m lg. A rl Lli Laufhand therap y baioed on ' rulell o f splllallocomOlinn' I~ cfledlve III '> plIluppont:d u eadmtll and O'wergruond !tam Illp lJIot pat lem pu t t.crebrO\oll...:ular a.;clCient Neum Rehal\liltaUQn jb(3)
''''5.2001
24. True blood. PR : Panial body weighl treadmllllraining in persons with c hronIC 'itroke. NeuroRehabilitatlon l6(3}: 141 , 2001 . 25 da Cunha Filho. IT, el al : Galt outcomes afler ac ute !Moke rehabilItatIon with .. upported !readmill ambulalion traming: A randomized controlled pilot study. Arc h Phys Mcd Rehabll 83(9,: 1258. 2002. 26 . Ada. L. el al : A lreadmlll and overground walking program Improves walking in persons re"lding in the community after stroke : A placebo-conlrolled. randomized Inal. Arch Phys Med Rehabil
84(10),1486. 2003. 27. Sullivan. K. Knowlton. B. and Dobkin. B: Step training with body weight support: EtTect of treadmill speed and practice paradigms o n poststroke locomOl0r recovery. Arch Phys Med Rehabil 83(5):683,
2002 . 28 . Barbeau, H, and Rossignol. S: Recovery of locomotion after chronic ,)pina1ization in the adult cat. Brain Res 26:84. 1987. 29. Lovely, RG, el al: Effects of training on the recovery of full -weightbearing stepping in the adult spinal cat . Exp Neurol 92(2):421.
1986. 30. de Leon, RD. el al: Locomotor capacity attributable to step training versus spontaneous recovery after spinal ization in adult cats. J Neu rophysiol 79(3): 1329,1998. 31. Visinlin. M. et a l: A new approach to retrain gait in stroke patients through body weight support and treadmill stimulation. Stroke
29(6P 122.1998. 32. Mlyai, I. et al: Long-tenn effect of body weight-supported treadmin training in Parkinson's disease: A randomized controlled trial . Arch Phys Med Rehabil 83( 10): 1370, 2000. 33 . Holden, MK. el al : Clinical gait assessment in the neurologically impaired. Reliabiliry and meaningfulness. Phys Ther 64(1):35,
1984. 34. Russell. DJ. et al : The gross mo tor function measure : A means to evaluate the effect!. of physical therapy. Dev Med C hjld Neurol
31(Jp41.1989. 35. MiJczarek. JJ, et al: S tandard and four-footed canes: Their effect on the standing balance of patients with hemiparesis. Arch Phys Med RehabiI74(3):28l, I993. 36 . Neumann , DA: Hip abductor musc le activity as subjects wilh hip pros the~es walk with different methods of using a cane. Phys Ther
78(5),490. 1998. 37. Lev.mgie. PK, and Norkin. CC: Jomt Suucture and Function: A Comprehensive Anal, sis, ed 4. FA Davis. Philadelphia. 2005 38. Ely. DD. and Smidt, GL: Effect of cane on variab l e~ of gall for patIent!> WIth hip disorders. Ph)":> Ther 57(5):507. 1977. 39. Slephan, KM , et 31: Functional anatomy oft~ mc:ntai representation of upper extremity movemenb Ul healthy subjeCts. J Neuro ph) i>loI73(1):373, 1995. 40. Kohl. RM , and Roenker. DL: Beh;)\ ioral e\'idence for shared mechanismll between actual and imaged motor rei>ponse, J Hum Mo\ SlUd 17: 173, 1989. 41 Overdorf, V, et al : Mental and phy~ical pmctice i>chedule~ Ul acquIi>itJon and retenllon of nmel timing ~l..tlb . Percept Mot Sl..IU" 99( I ):51. 2()()4 42. LIIl , KP. et al : Menial imagery for releaming of people after brain IIlJury. IkalJl InJ I S( 1 I ): I 163. 2f1O..1 . 4 3 Dav I ~. FD. and Vi , MY: Improving computer \1"lItrotlJung Bch..t\ ior Jllode llilg. lIymbohc mental rehewlIoal, and the role 01 I..JlO~ ledge ~ truc lures . J Appl Ps}chol !S9(J):509. 2004 44 YtlO, E, Park, E:. and Chung . B Mental practice effe1.·t 011 hneIraclOg .K·cura&:) in pen.on~ "-Ith hCJlUP;u'l;!Ul' ')trol..e: A prl!"llInmoUY MuJ}. Arch Ph )'~ Med Reh..tbll !{2\9): 121.'. 2<XH 4 ~ H.lIl . Je· Imager)" pra(lu.:c and the de\elopment of wfgl .... ,),1 ...1.111.') Am J Surg IlH( 5):465 , 2001 . 46 Yal1 Uel. L. e l al . A menial WUIf! 10 mOior leanlln~,' hUPRl\ Ulg trajC..:to nall..lIlenlJtl(:') through Imager) lrauung Betw, SrJul Re.\ '1(.1 195 1'1'18
1)60
Ph""in l Rr h a bilil altOn
S uppl e m e nt a l
Rc :tditlj! s
IkluHloIn_ .\ 1\. , ('1.,1 r ''ubmaxllnal e>..crci:-.e Jeveb wa~ docu mented in thei r ~ u b jett~ y,;i th chroni c obstructi ve pu lmonary d i&Ca~ (COPO ). mcretbCd mJ.>.lmal aerobic capac ity wa~ also documented. 1 Recondi tioning of pat ie nt . . with pu lmo nary disease W,h fou nd to be po.. ~iblt:! COPD :.IMhma. and cyStiC fibrmis are the mo~ t COIllnl(m liuonl(' ob~lructlve lung djs('a:-.e~ for which pu lmonar) rehablilliillon is rende red. Pmiell t:-. w ith restrict ive lung di~ea~e have al,,>o demon~tr'iI~d lI11 prUVCJlle lll In fU llclional :.tbl!ttie~ following. pulmonary rehabilit atio n." Reha bllnallon for palJelll'i \\ ith c hronic lung d l:o.ease i .. Ilov,. a ~e!l -tMub!.\h~d and ",idely accepted mea n ~ of opt il1l lLing function'
Phy~ica l Therapy Management 572 Goals and OUlcomes 572 Examination 572 Exercise Prescription 576 Pulmonary Rehabilitation 577 Home Exerci~ Programs 578 Multispecialty Team 579 Palient Education 579 Secretion Removal Techniques 579 Venlilalory Muscle Training 582
SUlllmary 585
In thi s chapter. the most commo n chronic pulmonary di sease s are di sc ussed , as we ll as the physical therapy e xaminution a nd treatment of patients with chronic pulmona ry di sease. A b rie f review of ven tilati o n and respirati on is warrant ed for a bett e r unde rstanding of the di sease pat ho lo g ie s. and for unde rstandin g the rationale of the ph ys ica l the rapy procedures. The supple mental readings li st al the e nd o f this chapte r contains refe rence s for a more thoro ugh revie w o f respirat o ry phys iology.
Respiratory Physiology A ir is inspired th rough the nose o r mouth , throug h all of the cond uc ting airways until it reacheS the distal res pira ~ lOry un it, whic h cOlllains the respira to ry bronc hiole. alveo bI' duc t ... a lveo la r IooJ CS. and the a lveoli ( Fig. 15. 1). The move me nt 01 a ir thru ugh the c onduc ting airways i.s tt' rm..::d ~ '(' IIft!(l/iulI. A t full i n~p irali o n , the lungs contain thei r m.c ur.,JOn . There are change~ in (he all gll men! 01 ti~l~ 01 the d l a phfa~m w ith hY(X'flIl11alion . The diaphragm beL\ IIl1C~ natter. or Ie")') domed . The angle 01 pull 01 th~1,: fiber~ ch:inge~ .l~ the dl ~e'l ~ prog.l c~!)e~. altenng. the b1orneLllaJ1IL.'lo 01 the Ihora>. . In \c: \ ere d l~~\e. the diaphragm flb..::r alt£nmcnt IllJ) be honlolllal. re~ull lllg III an m\-\.dnl tnouon 01 Iht: 1{1v.C'r nb~ during mhalatloll (Fig I~A) . 8 rt .. ,h ~ou n(b and he.lft ~ou nd \ 111.1) he dl ~ ldnl ..HId dlffilUIt to hl'..!r PdftJ.t1I ), ub~lru c led bronchi tlnd hl'lIH cnlule" lHiJY rc ):'ult III t'A plflttory v. hec.tlng. Crad.lc~ 111'1) al!i.o Ix prC'lot'nl H)perlrophy 01 al:( el)~or) 1l'llI')(' l e~ 01 Ventllallon , purw d - hp hrealhlll g , C) ~U10" I ::", a nd d lgll.tl
Obstructive
,-
r-
~
()
-
TV
ERV RV
"""'1.
«
a-
..piratory fl ow rates measured during stab le periods are good indicators of the progress ion of COPD. The patient'&age, severity of a irway obstruc tion a~ measured b) FEV I and level of d ys pnea are co rre lat es of mortal 11) .1'1 ~.14
o
Asthma A~lhm~ I~
a common chronic pu lmonary di sea~e. affec tin g approx H11alcly 14.9 mil lion person\. 15 The d i. . e"!':!c is c h..u . aC le riL.cd by ('pi ~od l l' periods of reversible airway narrowlIlg III the pre~enc l' of aeroa ll erge ns. irr itant!':!. or t!),e rl·i. . \! . Airwa) narrow lIlg is due 10 mflam matl on. ') llloOlh 1l1u!':!de hrom:l! mpu\/II . and lnc rea. . ed airway !':!el:rt: l ion~.16 The~~ a llad.~ improve ei ther . . pontaneously or "" ilh medu.'al intervenllon and are m l er~persed "" ilh int ervah th at a re \) mptom free . Diagno~i~
The dlagno~i ~ o~ aMhma is c1i nica ll ) based 0 11 a hiMory of epl!>odlC wheezlIlg, short nl!s.!. of breath . tightnes. . 111 the
chest and/or cou ghing whi ch may be worse at night in tItt: abse nce of any othe r obvi ous cau ~e . The force~ e"piratory volume in one second (FEV 1) during e xacerbations wiD be less than 80 percent o f the predi cted value. With the"'01 a resc ue drug (inh aled short- ac tin g beta, agonist). an improveme nt of a t least 12 percent in FEV I should be demonstrated .
17
Etiology There is an assoc ia tion between asthma and allergy. Air· way hype rreacti vity, gene ti c predi sposition. indoor and outdoor e nvironme ntal irritants , infections. and active air· way infl ammati on has been impli cated in the developmem of asthma. 17 •18 Symptom s of asthma may begin at any age,
Pathophysiology T he major physiolog ical manife station of asthma is wide· spread narrow ing of the airways in response to a trigger, suc h as a cold e nvironme nt or othe r irritants! infections, or cigarette smoke. The airway narrowing occurs as a result o f eosinophilic infl a mmation o f the bronchial mucosa. bronc hospasm , and inc reased bronc hial secretions. The narrowed airways inc rease the resistance Co airflow and cau se air trapping. lead ing to hyperinflation. These narrowed airways provide a n abnormal distribution of veow. lion to the al veo li. E ven d uring periods of remission, SCIDe degree of airway infla mm ation is present.
Clinical Presentation The cli nical symptoms of asthma are cough. dyspnea. and wheezing during quiet or forced exhalation. During an acuIt ex ace rbation. the chest is usua lly held in an expanded p0sition. ind icating that hyperinflation of the lungs has oecurm1 Accessory muscles of vent ilation are used for bfeaIbioI. Inte rcosta l. supraclavicul ar. and subste rnal retrac,;OIIS may be presem on inspiration. Wheezing may occur during expirati on and c rack les may be prese nt. With severe airWaY obstruction , breath sounds 'TIay markedl y decrease owing kI poor air movemem and wheezing may be present DOl oaIy th roug hout inhal ation . but may also become presenI (II impi rmion. Chest radiogr aphs takc n during an asthmatic exa;erbl· li on usua ll y ind icate hyperinflation. as ev idenced by ID i n(' rea~e i n the AP di ame te r of lhe chest and hyperllJCCllCY of Ihe lung fi elds. Le~s commonly. chest radiographs IDlY reve al areas of infilt ratc or atelectasis from the bfoPCbiII ob,') truc ti on. NOll1lal chest rad iographs can be seen betwIII a ... thmutic {"xll('e rbations. The mOSt l'onsistelll c hange during an ex~ 01 asthma IS decrea.sed ex piratory now rates (FEV I). ...... volume and fun c tIo nal res idual capacity are ~ because of air trappi ng at the t!xpense of viUll capKiIY"" lI1 ~ plralOry re~e rve vo lume. w hic h are redIM*1 ftI rever&l bihty. of these pulmonary function test . . . . . 'r b ('haracten slte of aMhm8. Duri ng remission. . . ,... wuh asthma Old)' have nomlal or near-nonnaJ vaJuII.
r.
= Chapter 15 Chronic Pulmonary Dysfunction The Illost common art erial blood gas findin g during an aSl l1m~uic exace rbation i~ mild to modera te hypoxemia.
Usually some degree of hypocapnia is presen t secondary to hyperventilation. With se,vere attacks .. h ~poxcmia . ma~ be more pronounced and wull furth e r chlllcal dctenoral lon. hypercapnia occur~. indicaling the pati e nt is exhausted and
respiratory failure may fo ll ow.
Clinical Course By the time ad ulth ood is reac hed. man y ch ildre n with asthma no longer hJVC symplOnl s of the disease. 19.20 When the onsel of ~ymplOJ11 S begin s lat er in life. th e clini cal course is us ually more progress ive. show ing c ha nges in pulmonary function te sts even during periods of rem iss ion. Airwav remodeling in re sponse to the ch ronic eos inophili c
aif\va; inflammation is thought 10 be respons ible for the progre'.sive nature of the disease.
Cystic Fibrosis Cystic fibrosis (eF) affects the excretory g lands of the body. Secre t i on ~
made by these gJands are thicker, more viscous
and can affect a number of systems of the body: pulmonary.
pancreatic. hepatic. sin us. and reproductive. Dysfunction of the pulmonary system is the most common cause of morbidity and monality in patients with CF. Thickened pulmonary secretions \. . ill narrow or obstruct airways leading to hyperinflation. infection. and tissue destruction. Other presentations may occur due to the affect of the disease on other organ systems such as failure to thri ve. diabetes, sinusi tis. biliat) di sorders. and infertili ty.
Etiology Cf IS a genetic pulmonary di sease transmitted by an au tosomal rece~~jve trait. The incidence of disease in children is approxi mately I in 2,500 live binhs.21 Caucasians make up 94.6 pe rcent of all cases of CF in the Uni ted States. CF is l e~ . . com mon in the Hispanic (whi te and black) popu lalion (6A percent) and i ~ rare in the African-American population i 3.7 percent ).:!] The CF gene lcyslic fibrosis transmembrane regulator or CFfR) has been identified on Ihe long ann of chromo~om e 7. The CFfR function s as a chlonde channel in epithelial cells. More than 1,000 mutation ~ of thi ':> £ellt h,tVe been de~cribed and grouped into ~ j )( different du . . ~e~ . The 1110>; t common defect IS clas.. 2: defcl.:lI vc p r oct~ . . ing.~ 2
Pathophysiology Chrome pulrnonal) d l ~ea:-.e In CF i .. related II) Ihe abn urmal l) \'i~c{) u ~ m UL U", :-.ecreted by Ih e trac h~ ()bl'onl..· lllal tree. 'I he funct ion of Ihe lllucocdiary tlan"por! sy:-. km I~ Impaired hi' th e -
'--
te red in a pu lm onary rehabilitation setting- re stri c ti ve di se ases of th e lun g paren c hyma and pleura-wi ll be
Etiology
'2-"
r
e
0
TV
neurom usc ular apparatu s of the thorax. For the purpose of thi s di sc uss ion. those d iseases 1110St likely to be encoun -
Thi s group of disorders has a variety of causes. Numerous ag.ents. such as radiati on therapy. inorganic du st. inha lation of nox ious gases. oxygen toxicity, and asbestos exposure c~Ul cause dama ge to the pulmonary parenchyma and pleura and result in restricti ve pu lmonary di sease. The most common restricti ve lun g di sease is idiopathic pulmonary fibrosis (IPF). The eliology of [PF is not known : however. there is an immunological reaction in some cases.
'"e.
(.)
~
Restricti ve lung disease is a grouping of di seases wi th differin g etio logies that result in a difficully i~ ex pa~d~n g the lun gs and a reducti on in lung volume. This re strictIOn can come from di seases of the alveolar paren chyma and/or the pl eura. changes in the chest wall or an ah eration in the
presenred.
"u
< -< ~ ~
~
ERV; Expiratory reserve votume IRV: Inspiratory reserve volume RV; Residual volume TV: Tidal volume
Figure 15.6 Lung volumes of a healthy pulmonary system compared with the lung volumes found in restrictive disease. (Adapted from Rothstein. 1. Roy. S. and Wolf, S: The Rehabili· tation Specialist 's Handbook. FA Davis. Philadelphia, 2005, p 428. with permiss ion.) radiograph s. Radiographic ev idence of pleuraJ invol~· ment , when present, can a lso be seen. Pu lm onary function tes ts reveal a reduction in Vc, FRC. and TLC. Residua l volume may be nonnal or .... normal , and expiratory now rates remain near normal. Figure 15 .6 shows the changes in lung volumes and capacitie s that occ ur in re strictive pulmonary disease. Anerial blood studies show varying degrees of hypoxemia and hypocapnea. Hypoxemia at rest is usuallyeu:erbated by exerci se. Exercise may significantly lower oxygenation. even for patie nts with nonnal oxygenariooa re~l.
Course and Prognosis Restrictive pulmonary disease may have a slow onset bIi is chronic and progressive in nature. Survival depends 011 the type of restric tive disease, the etiological facton. and the Ireatment. Almost 50 percent of patients with lPF die wi thin 5 years of diagnos is.2b C hest radiogrolphs are inscDbitive indicators of the ex telU o f the disease. Hypetclf*l iii an om inous sign. indicating the temlinal stage of padmonary tibrosi ~.
Medical Management
i.
Medical manage ment o t ('h ronic pulmonary ..... II1dude~ ... moklllg ces~ation, pharmacological . . . . . . th~ u~e supplemental oxyge n. The followina provide~ a bnef destripuon of these;: medical inIeI
di.,
!
•
Chapter 15 Chronic Pulmonary l>ysfunction
group particip;lI ion w ith a health educator. behavior modi fi cati on. nico tine replace ment therapy. and the usc o f inh alers had an impressive 59 perce nt cessation rate among partic ipant s who we re followed al 4 month s. A 22 perce nt cesse in diaphragmaticexc uI"'\ion a nd more no rmal chest 'Wall excursion and lung mec hwllcllo.40 PO!!oloperativc re!'l uJ ts how \'ariable improve. mt:nt.ll. in e.xe l'ci~ ca pac ity, tung function. quality of hfe, and ga.s exc hange' In patic:nL~ \\-!th moderate dl~a.se-:u PliltCllb \.\ Hh wvere lung dl~ :l)e (FEV I S to 20 percent of pred icted) du not appear to bene fit from thi~ imervcmioo.
Thl' group 01 p.rients , ho" ed both a high monaltty role and onl y ~hgb t Impro\- emcnt in functional abillUe:, and '-lu a.lny (If hte ~cor .",!..\ A preorerati\-e pulmonary re.ha ~ bllualmu pro~rill1) IS aL!\()C'3ted a t man) c nteN Patients " ho p~u·u Ip3ted 10 pu lmuna r> rehabllil lion prnV' 10
LV K S dcmon;tratcd , hone r hospItal ,tay. and fewer day on nlt~lhaJ\I(;aJ H'Ilu lallotl .+' Lung rran .. pJdI'laIiOll fOt end.. ~I"~~ pUhnOI1M) lhwa.... ha~ n o\erall ~ur\'Y"" raw of
572
Physical Rehabilila tion Greatest Breathlessness
60 to 65 perce nt at 2 years and approximat ely 40 percent at 5 years:~5 The goal s o f lung tran spl ant ati on ~ re to rest? rc nonnal lun e. fun cti on. res tore normal exe rc ise capac it y. and prolong Iife.4t> People awaiting a lung tra.n s~l ~nt ll1~y include pari enls with emph ysema. cystic fibroSIS. Idiopathi c pulmonar) fibrosi ~. and pu lmonary hypertens io n. The nu mber of patient s 3\, ai ting lung transplanta ti on con tinu es to e.row. far exceed ing the number of orga ns avai lab le for ~ran!o\p l anta t ion . Thc average wait fo r a organ tran splan t is approxima tely 2,9 years, ma king transpl an tation a rea lity for only a sma ll nu mher of indiv iduah.: l7
Physical Therapy Management Chronic pulmonary di!\ease and its assoc iated dysfunction have a slow yet progress ive co urse, Th e pe rson with pulm onary dys fun ction often avoids ac ti vitie s that result in the uncomfortable se nsation of dyspnea. A slow but ~ t ea d ) decrea~e in the se pati ents ' fun ctional ac tivities fo l10\\ s. re ~ ul1ing in a prog ressive aerobic decond ition in g. It j, not un common for someone wi th pul mona ry dbea!-ote to h,1' c lost man) func tiona l abil iti es before ever seek ing medical help , The intended outcome of pul monary rehabilitation j, 10 interrupt this dow nward spiraling of ph y~ i· cal abilit). Improve funclional ca pac it y. and im prove qualit) of life,
G oals and Outcomes The Guidl' for Phy:o.U'o/ TherapiSTPractice prov i d~~ a general framework for phyo;;i cal the rapy in tervention for pallent '> wilh Impaired ventilation. re!-otpirallon. and aerobic capau t) and endurance a~ ... ociated \\ ith \enti latury pump d) !lfUnCllOn (Practice Pallt:m 6F) ..l1'o The deve lopment of . . pe ti onal ab ilities of patients wit h pulmonary disease. A GX! protocol. usually utili zing a Ireadmill or cycle ~rgorneser, gradua ll y increases exercise inte nsity in order to streSS the patient wi th pu lmonary dysfunction to the pain( of tUnicalioll. Vi tal ~igns are monitored throughout the test to e~ safety. The ECC, t:onlinllo usly recorded during exercise, records the exe rcise heart rat e and electrical actjvity ofcbr rarJiac t:o nduc tion ~ys te m . Blood press ure measurements
C haple l'" 15 C hronic Pulmonary Dysfu nctio n
575
Table 15.5 Exercise Testing Protocols Used fo r the Pa tie nt with
I
Walk Test (6· or 12-minute)
American Thoracic Societyl American College of Chest Physicians S7
Ambulate (wal k) as fa r as possi ble in the allotted time
10·M Shuttle Test
Revil1 59
Walki ng between two markers, 10 m apart, at increasing walking ve locities, wh ich are synchronized to an auditory signal or metronome
Cycle tests
Jones60
Begin at 100 kpm, increase 100 kpm every minute
Berman61
8 egin at 100 kpm , increase 100 kpm every minute. or 50 kpm if FEV , is < 1 U s
Bruce 62
Begin at 1.7 mph, 10% treadmill grade; increase both speed and grade every 3 min
Naughton63
Begin at 1.2 mph 0% grade; increase speed and 3% grade every 2 min
Balke-Ware and Ware 64
Begin at constant speed of 3.3 mph, increase grade 3.5% every min
Treadmill tests
recorded at 1- to 3-m inule interva ls during exe rcise and during recovery fro m the test. provide informati on o n the hemodynamic status of the patie nt. A BOs measured du ring exercise provide the best method for determ ining arteri al o>..ygenation and the adequacy of alveo lar ve nti lali o n , though the invasive nalUre o f thi s test lim its it s use. Arterial oxygen saturation mon itoring prov ides less infonnation . but the noni nvasive nature of the test m akes its use more \\ idespread . A number of these protocols are o ut lined in Table J 5.5.~7-{)4 The sy mpt om-lim ited OX T req uires the pati ent to continue the exercise protocol un ti l sym pto ms dictate cessation. Cri teria for stopping :1 pulmonary exerc ise test are prese nted in Bo>.. 15. 1. The IO- Meter Slltllr/e Te st (IO-m Shl/rr /e) is a wa lk ing protoco l that u se~ a recorded audio s igna l to dictate incremental wa lking ~peed~ on a Ic\!c l IO-ll1 c tt! T fie ld . The res uh s of the IO -m S hu tt le have a po~ itive corre lation With Vo!.w The 12 - or 6-Millllte Walk Ti'S ( ask s a patIent IU cove r 3!'1 much di stance a~ poss ible in tht ti llle frame gl\en. The 12- and 6-Minute Wa lk Tes h have been shown 10 be a good predic tor of functiona l abilities .5~ 801h the IO-m Shull Ie Hnd the limed wal k te~ I S art; ea~y 10 admllli~ te r and the ready aya ll abillt y o f the required equIpment make them good lOob for pre - Lllld pO!'lt exe rCISe llleLis uremenh . Refe r 10 the ~ec t io n on eM! rC J ~C lest 109 III C hapt e r 16 for more info rmatIOn o n cxc n.: i ... e proloco ls
Dete rmi nation o f fu nctiona l capac ity u s in g by an cxerc ise tes t all ow s fo r appropriate vocational co unse li ng and providcs the necessa ry doc um e ntation fo r address ing di sa bilit y.M T he need fo r s up ple m ental oxyge n is indi cated if a p atie nt becom es hypoxemic d ur ing the e xe rc ise te st sess io n . A decrease in the PaD., o f less than 55 mm H g , co rrespo ndi ng to an Sa0 2 o f pe rce nt o r less. ar e
88
Box 15.1 Graded Exercise Test Tennination Crite ria I. Maximal shortness of breath Pa0 2 of greater than 20 mm Hg or u Pao:z less Ihan 55 mm Hg 3. A rise in Paco~ of greater than 10 mm Hg or g re~ter than 65 mm He 4. Cardiac ischenll u or arrhythmias 5. Symptoms of fat igue f, Increase in diastolic blood pre~sure readings of 20 mm Hg. s),slolic hypenc=nsion greater [han 250 nun Hg. decreas¢ in blood pressure with increasing work loads 7 Leg pain k Tutal fatig ue Sign ... of insuffiCient cardiac o ut put tn. Reaching a \enli latory maximum
2. A fall in
l.
\-rom Hranmln. F. l't .11 : l'.udwpuII1\OIl.lry Rdl.lbllh.ll lon: Ba~k Theor} and Applil'3tioll. FA Di.!1 il>. Phitllddphla, tQ>')M. p ~OO. ~i l h Ik'nn!\~lOn
576
Physical Re ha bilitatio n
i nd,cation ~ of a need for oxygen supple mcn tation d uring cxe rcise. \Q.tItI • PFTs performed prior to and fo ll ow in g an exe rc ~sc test dOClIlllCIll (he effects of exercise on lung func tIO n. A reduction of 15 perce nt in FEV r is a n ind it'ation of a p~s itiw pulmonary le ~I.M Fina ll y. a presc ript ion for exerc Ise that \\ ill safely promote cardiopulmonary ~tnes s ca n be developed based on the GXT. T hi s is th e top IC of the nc xt secti on.
Exercise Prescription Exe r cise presc ript io n incorporates four va r iab ~ es that togethe r prov ide an indiv idually ta il orcd exe rci se. for 1l1~1i.l dc s ig ned 10 produ ce an increase in fUllctr~nal capaCil ). The se variables are mode. int e ns it y. duratIOn. and fre-qu e nc).
Mode
An ~ type of sustained ae ro bic exerci se is recom mend.e d for pulmonary rehabilitation. Lower ex tremi ty (L~) act I Vitie~. including walk ing. jogging. row ing , cycl in g. and sw imming. are recomme nded 10 improve exerc ise tolerance. Upl~r ext remit y (UE) ae robic exerc ise, arm ergo~ etr). or free weight s should also be inc luded. The com bi nation of UE and LE training in a rehabilitation program re ~ u1Ls in improved fun ctional status compared to e ither exe rcise ~doneY M:tlly program s util ize a c ircuit approach to train different muscle groups and maintai n thc partici pant 's interest.
Intensity Three parameters used 10 prescribe exercise intensily are oX),f!en con::. umption. heart rate, and 0 Raring of Perceired £.H' rtl(lI1 SllOrtllf'S!-J of 81'£'arll. Be low is ;} disc uss ion of each meam of pre::.c ribi ng exerci se inte nsity. Exercise I nte nsit y as a Percent of \lOmAX . A GXT re p o rt ~ fun cti ona l capac it y in lerm s of V0 2rn3~' E"erci'le inlen~ity ca n be prescribed using 60 to 75 percen t of the max imum \10, ac hi eved on a GXT. Patients with ~e\'e re pulmonary di ~ea:,c ma) not tolerat!! long periods of ac ti vi ty al thi~ le\el. Lowe ring exe rc ise ifllen ~ ily may not he the an ... \o\e r 10 thi s ... itu alilln a ... l e~ ... e r 10 no training e ll ecb ha ve bee n tound by usin g lowe r pe rce nt ~l ge~ of VO ,.hi'> RJ.the r. e\e rc r ~e \\ ill be lO\ c rateJ and a training elleu ClL hJt!\'cd whe n ~ hOJ1 bur.')h of ac tr \ it) at up 10 60 to HO and eve n up 10 95 pacent of VO ~"I~\ are inl.anli ned using a si milar rating scale and show n to correlate with VO ~-1; (Tabl e 15.7). R ating~ between 3 (moderate ~hortne'is of breath) and 6 ( between severe a nd ve ry "eve re shonnc, s of breath) define the range within whi ch patIents \\ ilh pulmonary dy~func t ion gene rall y exe rcise. A rating of 3 corre~ pond" to approx im ately 50 pe rce nt of YO _1Il.1 , \ . A ratine:- of 6 corre:-,ponds to approximately 85 percent of VO ~nlJ.:l:M The pre.;;cription for exerc Ise inten~ity sho uld incorporate symptom\) of shortness of breath and percei ved exertion . rather than being based ~o l ely o n THR . fi xed work le\eb. or Vo~. ClinIcians often prefer to presc ribe exe rcise
577
Table 15.7 Rating of Perceived Shortness of Breath Scale --
ro
-
0 .5
I
------
Noth ing at all Very. very slighl Gust noticeable) Very slight
2
Slight
3
Moderate
4
Somewhat severe
5
Severe
-- --6
Very severe
7
8 Very. very severe (almost maximal)
9
Maximal
l2,O
by util izi ng a combination of presc ripti o n by THR and
Table 15.6 Rating of Perceived Exertion: The
RPE or perce ived sho nness of brea th parameters.
Borg CR 10 Scale
The Bore CIUO
a
~~ --~--~------~~~ "No P" Nothing at all
0.3
0.5
Extremely weak
Just noticeable
---
Very weak
15 2
Duration Exerc is ing within the THR for at le ast 20 to 30 mjnules is recommend ed. The dural ion of t,h e training sess ion vari es accordin g 10 pati e nt tole rance. \\ ith ~ome panicipanls not being able to maint ai n continuo us c'(e rci.;;e for 20 to 30 J11inut~ s . Frcqu ent re~t pe riod s can be inte rspe rsed with exerci~e to accomplish a to tal of 20 to 30 l1linute~ of di:,con tinu ou~ e,e rt·ise.
Fn.'quency
Weak
8
The frequenc) of e;..erci~e refer, to the number of M!,,~ions perfomu:d on a \\cd"! ) b~lsis. during the c\cn.:ise tr~linlllg perio l"lders mu::;t be 10110.... 00 See BOl9 G 1998 Borg & Percell/ad Exertion and Pain Scales Humc:in Klnellcs, Champaign II 01 wwwbOrgplodoct& com WIth perndSSIGn
I
\'·f(,bi(.: I rait.ing rill'
.'Cltlhl~ tJJlHln):!
..,c--"itll\
POIIIOIII.I I
J plllnwnal )
reh:lhilitatllln
uldud. ..', tlu..' !ollll\I,Hlg C(llllptllleHh l·h.,."t ].., -III, \\ann-
lip ,tCrulll C \.·Xl.:fU . . \.' . "wd I..TM.ll - dv\\11 P~IUlill') J IIIII ~
pt~nion
Ml.ld lfic'-llion... 111 the dura tt on and Inll: lhH Y 0 1 Ihe c>.L: r L: I W 'It:~'lon .\houl d be Ill ude a~ an indJ\ Idual phY"'lOlogll'all y
ad apts to exe rc ise. Exe r~ i se pro~ress i~n is appropriare when the individua l pe rceives Ihe mtenslly of the exercise .\es~ i on 10 be easie r or when the same exe rc ise intensity is perform ed with a lesse r deg ree of shortness of breath and lowe r hearl rat e. Exe rc ise progressio n shoul d first be directed toward increasing the duration of exe rcise by extending the amOUnt of time spe n! in contin uous aerobic activ ity and decreasing Ihe amounl of time spent in resl periods. The goal of duralion progression is 10 achieve al least 20 minutes of cantin. uous aerob ic acti vity without the need for a rest. When 20 minutes of aCli vity can be accompl ished. then an increase in exe rcise in tcnsily can be proposed. Frequency should be adju sted as necessary, based on durati on and intensity. A pati ent 's age, fun ctiona l abi lity, symptoms. and severi ty of di sease must be considered prior to any change in the exerc ise presc ription. When conside rable change in a partic ipant 's ab ili ty has occurred, it is advisable to perfonn a new GXT. The new exercise prescription will allow ror a safe and comfortable progression of exercise under controlled guidance.
Program Duration Improved exe rcise tolerance can occur during an inpatient hospilal adm ission, as an out patient. or with a program of home- based care. I Because of the limited length of stays for many hospital adm issions, most increases in functional capacily occ ur during an oUlpatie m or home program. Ge nera ll y. conditionin g exe rc ises are conducted up to Ihree times per week over a course of 6 to 8 weeks. At the end of th e re habilitation prog ram. both qu ality of life meas uremenlS and functional abili ties should be reexamined. A n exit exe rcise t e~1 may be performed to assess the exercise prescript ion for cominuat ion of care. Although GXTs may prov ide a wealth o f c li nical infonnation, a 6- 01' 12-Minu te Walk Test or the IO-ttl Shuttle. with their e3.l< of ad minislratio n. makes them a vaJ uable pre- and post· pulm onary rehabilitati on program measures.
Home Exercise Programs A home exercise program (HEP) begins while the participant is ~ti l l t'nro lled in ~Ul ou tpati ent pulmonary rehabilitatioo pr0gram. \Vhen the team deenb il fca~ ib le (based on exercise· and laburinory dat~l) , Iht! pan ic ipanl can be assigned exercise i.tl'\I \'i lil'''' to be done at h0l11e. The patient returns to the outpatit: nt dink' \\ irh an c\.cn.'i:-.e log containing the heart flit, RPE .... I,:'\l'r~ l !'!e panllllett: r.... and :my problems tJuu may hro'f O("Cu l"IL'd dUI"Illg the home prt)~r..lm . lne team analyzes me dal,\ ,lIltl atljll:"l~ lhe home prol.!,~·," n if lIece!)~ary. ProgressMJI 01 the p.url· nl 10 i.I home progr;.~n and 10 inde pendenl e.xen;ise I.....111 impl)rl ant goal of tht' n.~h ab il i lation progf'.1Il1. All unfonu natt' It,~ al n) " Ihat patjents with pulrnOldY rotaIlI5 " . kim IIpWtlrd UW-Ieg is fleX@(! a.9f a plliooo
Pallenl lin on fIbdomen , ~ down, wilh pollow I.InOO< hip$. Thttr_t clap8 0'01If lower dose )() spine Ofl eacf'I alOe.
Pahefll &es on atxIomen w,1t! two ~
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IPoIIIion chown i$ for drlllt'lagl 01 rig/lIlllI.IRll basal seomenI. To dram the left late..haled air l':llhC'" an illlenniltent b.ld.,\\ard air pre~:.-.ure that Jar') tht: air\\ .1) .... The u .. ual prtI ACLI\t' l· \h.tl~tthm 1\ against a
Physica l Re h ab ilita tio n
582
' h
t PEP has bee n shown to be equally effective to
w it OU . . 'd h k' 798U postural drainage, percuss ion . an s a mg. '
Ventilatory Muscle Training
FIgure 15.10 The :Jcapclla device used for an ind ependent prog ram of ~t!c rction remova l. (Co urtesy of OHD Hea lthcare. \Vamp ~ \'ill e. NY 13163.)
positive expiratory pressure. Low pressu re PEP uses a
re:-.istance that v. ill measure 10 10 20 em H")O , - during mid exhalation. After approximately 10 breaths. th e mask is removed and the patient huffs 10 clear secretions. After a '
brief reSI period. the routine is repeated until all secret ion s have been cleared from the airway s. For patients with unstable airways. high -press ure PEP of 50 10 120 em H10 can be used. High press ure PEP requires that the resi stance be individually set at the point whe re the patient is
able to ex hale a larger FVC with th e device in place than
Figure 15.11 The. rr:p . . )~ tem fnr an lI1dependeOi pn>gram ul !tt!(;rellon relllOv,lJ DHD Ilt:aJlillare. WUJnpw iJJt', NY (('ourle,,) 01 DJ-ID Heallht .thC:, Wamp.w ll le, NY UI113.)
The inability to sufficient ly increa s~ v.e.ntilation and the se nsation of breathless ness may ~e. l.lmltmg factors in the performance of functional .actl~ltles an~ exercise in ' t ' 11t s with pulmonary dysfunction. Ventilatory muscle ~Ie ' " , , training dev ices provide resIstance to the msplfatory phase. the ex piratory phase. or both phases of ventilation in order to improve stren gth and endurance of the muscles of ve ntilation (Fig. 15.12). Many research studi es have demonstrated the ability 10 increa se ven tilat ory muscle strength and endurance ll sing these loading devices, especially in the presence of ~, ' k n es s. 81-87 Ven t'l known respiratory museI e wea 1 atory mu scles train ers have al so been stud ied for their ability to alter th e perception of dy spnea. While results varied, a number of studies have demonstrated an improvement in the sensation of dyspnea wi th inspiratory muscle train· ing .82-1l4.86 Most importa ntly, the question is whether training the muscles of ventilation translates into a clinically signifi cant functional improvement. Statistically significant changes in 6-Minute Walk Test and Shuttle Walk Test have bee n demonstrated.83.84.81 However, these changes do not always trans late into a clinically signifi· cant imp rovement. For example, a change of greater than 54 III needs to be re alized on a 6-Minute Walk Test in order to be clinically s ignifi cant. 88 Although Weiner et al ~3 found a statisti ca ll y significant increase in distance
on the 6-Minute Walk Tes t. the increase was less than 54 m in two of the three treatm ent groups. The meta-analysis by Lotters SI stat es th at the abi lity [Q affect functional improve ment by th e lise of ventilatory muscle training is ye l to be de term ined. Wei ner et al s3 present infonnarion th ai sugges ts venti lalOry muscle training may have different effects based on the patient's severity of lung disease . In patients wit h seve re di se.use and documented in sp iratory mll~cle weak ness. training improved their ventilatory mU 'ic lc function. However, in patients with
Figure 15.12 A Ihn:,hokJ in'plnltory muscle truiner for ~ U'ol' III Ilnpro\ HI!? ~ Irellglh and l'r1(jllrum:~ of Ihe mu!tClts ot lII\ plmllllJl . / ('OUlll.'~) of Fitlll'~'" M al1 i1>. [Country TedUlokltY' hKJ. (j,IY, \illb-, \\ I "4h~l.)
Evidence Summary Box 15.5 Ventilatory Muscle Testing
D ....
Subjects
Larson. JL et al S2
53 patients with moder· ate to severe CO PO
1999
Weiner, P, at al 83
32 patients with COPO,
2003
FEV 1
' I!oon, R' LlmH\ trul.ll \e pulnlOrWr} dl \('a.'oc. ~ HLll I/WH O 'Inh,jl U1ltIMI\l' lor chronIc oh,tnlctlvc lung dl-.e;I"l' ((,OLD ) work:hOP !iUlllmar~ Am J Rc~pir C rit Cart: Med 16.1: 1256. 200L 7. ~ 1 :lI1m. JB. el al' ~lca~urcmcnl (If IIhpirahJt: lllu'\Ck pe rformance .... llh ·uxrcmentalI111\.'~hold loadmg. Am Rev Rc'pir 01 ' I J5:tJI 9. 1'187. 8 Ccllt . B nil' Imro nJnce o f ' pirulllc lr~ In COPD and a. Am JRe'plr Cnt ('arc Med 168: Im4. 200:1 . Bnll, h Tho rac ic SociCIY: Standard e.Cl IO C he\1 ~kd 18:173 , 1997 . 47. Organ Procure mcnt and Trans plantatIo n Nctwor ~ and the Scienlllic Reg i!>try of Tran ~ plant Receipienb (OPT/SRTR): 2003 . Re tricved February 12. 2006 from hnp:llwv.w.optn.org/AR 2003/defaultJllm 48 . American Ph y~ical Therapy Associalion: Guide (0 Ph),sical Therapist Practice. cd 2. Phy ~ Ther 8 1: I. 2001. 49 . Mahler D. el al: The impact of dy!>pnea and phys iologic function in gcneral heallh !>lalU\ in patients w ith chf(ln ic obstructive pulmonary d j~it~. Che~ t 102:395. 1992. 50. M:rhler. 0 : Oy ~pnca : Diagnos is and management . Clin Che~t M ed 8:215 ,IY87. 5 1. Guyau. GH , d C a ~e . Eur Respir J g( SuppI1 9 l. 17 1S. 1995.
S u
l e mental
Readin
77 Konslan. MH, el 31: Efficacy ~f the fl ~uer de~ice for airway . mucu.\o d eara nce in p;mdv. ie hed between two co nnec tive t iss ue layers: the endocardium o n the inner Mlrface and the e picardium, which fo ml ... th e ou ler &urface. Th e e nd ocard ium is in contact wi th the blood that fil b the ve nt ricl es, while the epi cardium is in contact wi lh th e peri ca rdial fluid. T he endoc ardium no t only serves as a lin ing for the inner s u rface of the c hambers, but al so co ntribut es to the forma tion of th e va lves. Th e va l ve~ are co mpo sed o f de nse con necti\'e ti~ s u c, T he ep icardium lin es th e o uter s urface of the he art and fo rm ~ th e vi~ceral laye r o f Ihe perica rdial Stlc. The pe ricardiu lll s urround ... and c ushion s the heart; it... I\'.o layer~ are th e o ul e r parie ta l la ye r and the inner vl\ceral layer (the ep ic ardium ). Be tween th e~e two layer~ I ... peri cardial fluid , whic h se rves a ~ a lubri ctume
d e pumplJlg. blood v. . . . . . . . blood volum". (AtIajlIedVanJer. AJ. S.......... IH. . . LUCIIUlO. OS: HUIDIA ~~=r1~ McOrol~ ~ HIII, New ~
Chapter 16 Heart Disease Sy!iaolic ~U1d diastolic measures are Ihe most cOlllmon clinical measures of SP. However. the mean arterial pres· SlIrt' (MAP ) is an imponant measure to use in the cr iti cal care se lling (i.e. ICU ) when the goal is 10 keep MAP > 60 mm Hg. The MAP is th e arterial pressure within the large arteries over time (the cardi;.}c cycle) and is dependent upon mean blood now and arterial compliance. 1J It may be approximated b) taking the sum of the systol ic pressure (S BP) and t" ice the diastoli c pressure (DBP) and dividing by) (e.g .. SBP + 2 DBP .;- 3): a BP of 90/60 wi ll therefore have a MAP of 70 mm Hg.
Cardiac Output The c:oal of the hean is to provide adequate cardiac output (CO l and. therefore. ::terobic e ne rgy for the body's metabolic demands. Because the energy demand s of the body are constantly changll1g. the hc;:U1 'S CO must also be ab le to adapt to the changing systemic energy demands. as well as to it s O\~n myocardial oxygen needs. Innue ncing CO are three key physiological principles: (1) adequate oxygen supp ly to the myocardium b) the coronary arteries: (2) contractiliry of the myocardium through its propenies of diastole and sys· tole: and (3) fonnatjon and conduction of an e lectrical impulse from the sin us node to the ventric le s. CO i ~ defined as amount of blood that leaves the ventri· cle ~ JX'r minute. expressed in L/min; nonnal CO is 4 to 6 L/min. It i\ IIlfluenced by HR (expressed as beats per minute /bpmJ) and stroke volume (expressed as ml/min). Stroke \"olume (SV) is the amount of blood that is ejected with each nl ) ocardial contraction and is influenced by three factors: ( I J preload. the amount of blood in the ventricle a t the end of diJ. . . tole (aJso known a:-, left ventricular end dias· toile volume, LVEDV): (2) cOl/lractiliry, the abili ty of the \'entri~l e to contract: and (3) afrerlaad, the forc e the LV mu ~t gene rate during 5y:-,tole 10 ove rcome aort ic pressure and open the aOI1JC val\-e. Afterload may al50 be de scribed as the "Io..td ... againM which the LV contracts during left \entncular ejcction .'·1 5 p '711 In genera l. stroke volume will IIlcrea \I, IIh an increase in prelo..ld or contractilit y and will decrea. . e 'W- lIh an incr~ase in afterload. Normally about 55 to 75 percent of the prdoad i~ ejected a::. the Sv. The tjec· lion frartion (EF, demonstratell thi :-, relationship between SV and LVEDV , uch that EF ~ SV .;- LVEDV. lIonnal EF IS apprm. lmah:Jy 55 10 75 pe rcelll : (67 ~ I:! pcrcc::nt II,) . EF i~ widel) u\Cd dmicaJly a~ an inde>.. of cont r;'lclili ty. J7 Cllnlt.:all) . ~~pcc lall y in cri li cal ca th3t aWJ.k(' lh thl'ill from ~ Iec p but , ~ rellc\ ed when they .b~Um l! all upnghl po:-. turc-. Tht .. I ... k.n o\~11 afl. 11aro \l JmaI Il OClIIrlw ll" ,pneo ( PN /)J imu i, a....oclated wi th LV fJliure. It j \ aho ullpnr
60 1
lan1 to ask the patient how many pillows are needed to feel comfOrlable breathing while slee ping. Pat ie nts with LV railure frequ entl y use more than one pillow to sleep; by elevating the trunk. venous return is sli ghtl y delayed and th e work of the LV is temporarily decreased. This is recorded as fWO pillo\\' orthopnea (o r whateve r number of pillows are needed). Orthopllea refers to the dyspnea that is influenced by th e effect of gravi ty on increased venous return (e.g. , occurs in th e supine but not in th e upright pO"-ition). In hearl failure. orth opnea may be exacerbated by the shift of blood volume from th e periphery to the pulmonary circu l at i on . ·~ Some patients ma y ex pe rience dyspnea as th eir anginal equi va len t: that is. they do not have th e typi ca l ches t di sco mfort oflen associated with ischemia but instead ex perie nce shortn ess of breath. Treat ment should be immediate and follow the guideli nes for ischemia.
Blood Pressure Arterial BP is a product of CO and PVR (BP = CO X PVR ). An increase in either of these factors will increase BP. and a decrease in either may decrease blood pressure. SP is normally slightly higher in supine than in either sitting or standin g because of the increase in venous return in the gravity-m inimized position . This increase in venous return contributes to an increase in CO. In the upright position, gravity will delay venous return and there wi ll be a transient. brief. asymptomatic decrease in BP until peripheral muscle contractions and sympathetic venoconstTiction are able to incrci.lse ve nous retum and sy mpathetic arteriolar vasoconstriction increases PYR. Although difficult to substant iate. clinical observation indicates th at BP usually normalizes within seconds to a mi_llute of standi ng.
Orthostatic Hypotension Orthostatic (post ural) hypotension is the sudden prolonged drop in BP that accompan ies a position c hange from lying to eit her silting or standing, COmmOJl ~y111p [Om S include Iighlheadcdncss. dizziness, and (oss of balanc~ ..11 A drop of systoli c blood pressure of more Ih:lJ1 10 mOl Hg be tween mca~uremeJ1ls (lying ven,us ~itting versu~ standing) i\ unac('cpIJble: a st;.mding HP kss than 100 mill Hg !'Iy~tolic may be abnormal. Both situation .. require funher clinil·al examination and IIl1crvcl1tion. '1 If the paticllI ha." allY of the above sy tl1Ptnll1~ \\ ith po~ition (; hang~ . ~ht' or he ... hould be mana gt!d a~ if th~n.~ \\] Once a MI has occ urred . the wound healin g process begin:... In general. th e stabilit y of the wound is es tabli shed \\ ithin the first 4 to 6 weeh . During thi s time. the pati e nt may engage in low- leve l activity, but aerobic training intensit) should generall y be ;.Ivoided. After 4 to 6 wee ks, it iii common for the patient to unde rgo a symptom-limited maximal exe rcise tolerance test (ETT). The treadmill is the 1110:0.1 C01111110n modality for exercise testing, and a variety of protocols mal' be followed. The bicycle mal' also be used. Most patients wiJI have a nega ti ve Err at thi s time, indicating that there is no a pparent ischemic myocardium al the work load achi eved. A positive Err means th at Ischemia is present at a ce rtain workload . The physician \I, ill report at what HR and BP the ischemia occ urred (the ischem ic RPP). as well as the time during the test it occurred. As a result of a pos iti ve lest, the phy sician may sugge!-t altering the pa tient's medi cations to provide more anti-Ischemic benefit s or sugge st a cardiac catheterization to dctemline the feasibility of a revasc ulari zati on procedure such as (oronal), arIel)' hypass grafting (CABG ) or Qngio"Ia.lf'- (PTeA). (see fo ll owing section). Afte r the ETT, patient \ may undergo an aerobic and stre ngth ~training prof!r:ul1 for the next 2 10.t month s. follow ed by a mainlenanc~ program. Ca rdiac rehabilitation and maintenance prugram \ include not j ust exerc ise but ed ucation and suppon for the ~uggested be havio ral c hanges and the patie nt 's indJ vid ual phannacological management.
Diagnostic Tests and Medical Management The cJa~slc diagnosti c tool for examining a patie nt's COI11 plaint of s u~pecled angina i~ the 12-lead EKG. If i ~c hemi a i ~ pre\cnI . the ST segme nt will be depre ssed, and the T wave may abo be inve rted (fli pped) in those leads corre. spondmg 10 the coronary perfusion pattern of the invo lved aner). he hemIC chaJlge~ will be present only while the l\themlJ I" pre ~ent ; when the i ~chemia has resolved , the EKG will retum 10 normal. II a transmu ral MI is presenl , a ("Cflc:-. of chungc!) Will occur; the ST wi ll initia ll y elevale. mdKalHlg ..til arca ot injury. C . The American A"I,oc ia tlon ul (.udIO\a,,·uJar unci PuJnlunar) Rciw.blillalion ~AACVPl{) c:\ tahIJ:o.hcd gUJ(lcJ IJlt!~ fur e\uluatlng a put U.:: 11 I \ appropn .Htne'')' iI)r. e . . er!,.;"'c pafllupullon 1 hc) rccomll1l'nti Ih t p:.tlle'nl ~ wllh the lullo" IIlg uUlliH IOl1\ he l'\c1udl.'d Ir\)111
.
exercise training: un stab le a.ngina. sy mptomatic heart fail. ure. uncontroll ed arrhy thmi as, moderate to severe aortil: stenosis, unco ntrolled diabetes, acute systemic illness fever. uncontro lled tachycardi a (HR > 100 bpm), systolic BP '" 200 mm Hg, resting diastolic blood pre~ sure'" I 10 mm Hg. thrombophl ebltts. as well as OCher conditi ons.?':! The patient shou ld be evaluated once tbtse conditi ons have been corrected and, when appropriate begin (o r res ume) the exercise program. Recognizing th • card iac di sease is a dynamic process, and that Ihe parie: who was stabl e and able to participate. in physical therapy las l ~eek may not be stab l ~ thiS wee.k IS a criti cal concept. The Importance of a pat ient-specific examinalion and evaluation prior to each session will allow the physical therapist to criticall y plan the appropriate intervenlion.
rem;
Exercise Intensity Inte nsity ma y be presc ri bed by e ither HR or by subjecli ve repo rt . a rating of perceived exertion (RPE). Subjecti ve ratings of intens it y of exertion have been used to quantify effort during exe rci se. The original Ratingof' Pe rceived Exertion scale (The Borg RPE Scalf). deve loped by Borg. has been used ex ten sively" (Table 16.7). " consists of numbers ranging from 6 to 20. which pat ients use to rate th eir pe rceptions of how hard they are working. Desc riptive wo rd s accompany the numbers, such as hard or very hard . Commonly, patients are asked to limit the ir exertion to between fairly light and some. what hard. Borg a lso deve loped a category-ratio scale of 0-10 (Chapter 15. Tab le 15 .6). Both local symptoms. such as musc le aches, c ramps. pain. or fatigue. and ctnb'al symptoms, such as fee lings of fa tigue or breathlessness, con tribut e to th e overall feelings of work perform:JQCe. Hi gh correlation of RPE ratings with HR and aerobic power has been found in nonnal individuals and in patie nts with cardiac disease. A ('OO11nOI1 aerobic exerci se prescription based on HR is 70 ~o 85 pe rcent of HRma.\' However, the more decondiIimed pallem may be aerobicallv trJ.ined at as low as SO 50 tJJ percent of HR rn....'. Any pa~ient who has documenled CAD ..,h()u ld have a medically supervised E1T before beg~an aerobic exe r~ i ~(' program. Without an E1T. it is impossible 10 a:, .. ume \\ hat the- maximum HR would be for a patient wa (.'a~ l .tc di.')Ca~e. 111C' EKG lllonilOring during the ETT ls __ lui III the detCtlion of ~~t!n.: ise- induced ischemia. lfthefCno E1T dat:1 dvailable, it i~ un\\. ise tu prescribe an b.l\cd on IIR~. Cau tious pmgres!t.ion of activity is ~ .Iong II Jlh U,c of RPE and 'nowledge of adv""" sigaI_ rnptol~l!t. fnr t.·\t:.' r~11ie illlUlcran~e. An easy toOl f« . . mOIlJlOlll1g I' lor lhl! patienl tn be able (0 taJk without becOIt' 109 hre.llhlt!~!o, \~ hde e \l·rl'l,iug. 11m. provi allo\\ "> palient:) 10 begin to lake responsibil11 \ for their (;hoice~ aft: n l lc n <J hi t.! dt:11 t'1Il"rg) l'lh[ p..tUCll h Jre \)lte l1 \cr) l·. . u tl'd alld rt' d\urt:J III 11.1\ l' \ 1'>111),-.... hu t th..: L.lIIgut' tlul 10111)\\" , ... ..,\lllll'
Lt?)'els 4 Through 6. Pati ents gradua ll y 4uenl')
11II1~ !oI \1.:1) lIJ'>l"IIIIL4.."rtlllg I klplIl¢! 11\1;' p JtJl'l1 l und l·r\t.uld !hl' l llll't:pt 01 t:11t:'rh')
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11t:lp Il le p..llllill 1(1 P"ivc hum idi ty and poor ai r 4ualiry). Some patienls are \c r) "'cl1'> lIl\e 10 environmenta l fac u.x~ and should exercise onl y 111 ,Imbtenl condit ion . . or indoor. . . For some parienb, home ~ ;\(' I\: i . . (' e4 u l pmel1 1 i. . affordable and muy be a rea· 'lo nab lc a ll c m ~ltl\ e 10 o lltdoor t"\c rl"i!'oC. For safety reasons. ,Ill ' p.itlCIlI , hDlIld Ix tll u n ll\ ll-ed on , [mitu c:q uipment before lIlut'lk' nLlcf1 (I, 1X'"l!.l nnln l! 10 exe n: i">t! at home. This b nollhe tll n~ 101 a pa ; ll'nt~1O II) ~i.I Ill'\\ I ) pe o f exerciite modality b&I h ) :.Ia) \\ IIh " hat i . . fHrl1lh~1I \V.llk ing. appC'ar~ 10 be thee:o.etll . . e III d 'llll'C \1\\ Ill ;;' Ii \ Ih \:J.~ e and tmnilianty. 'Ilw P;lIl l· IlI ·. . J~I\ \ \\ III bt.' d ( OlllbUlalion oJ rest and~ ' IL"\ l'i .llll\ II \. IIll l u{ll1lt\ Jlnbulation i.uld LE and UE JllObi.lilY. ri ll' P,ItH..'nt ,h~lu ld lx' l·II~\)Ural.!l~d 10 tn .Ulel change: posll~ III i..IllI\ 1\\ L"\l' l ) I III ~ hOlll . . t: . . ,IJ;lple, It i~ ge:ner.illy 001 d ~\~~lld ....1 hll" Ih.: JXil lL"llI lO hL' up .111 morlll tlg and then ~ .1I1.llIdlltll.m It 1.... lm.l lll.1hlt' Il) h"l\e p,ttIL' IU ~ \erbaUy ~ \\ 1t.1I tll\·" lld\ ~ \\ IU HI\. Iud..: l \lIl 'L" thl'} dl"C J iy:hargtd'lblS "111 111..1 .....1Il UPI "- ' IIlI IlU\ III tx-Ul'r undt.' r..,ldnd tht illteftSlS 01 • .jdc
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[0 d\.' Il'lllllIlC till' p.Ull' lIt '!. unde~UlflU"" ~'lllddlll ..·"" ..IIlU l' nl"l"t!) luI L'oC'(\dUQn tCIo.:hniqUC'i-
.\11 \IP'"l\) II UIH I)
Chapte r 16 Heart Disease
5 wee ks post- Ml o r 8 weeks pos t-C ABG .79 Some guide lines
Outpatient Phase II Patient s comlllon ty undergo a symptom-limit ed ma xim al
(ETn
6 weeh po si-MI. Bao;;ed
the resull s o f the tests, e ither pos it ive ( + ) for isc he m ia o r negative (-) for ilOc hemia. an exercise presc ripti o n is pre-
streSS fesl
al -' to
621
0 11
"c~bed . For a (-) ElT. a co mmon exercise prC!)C ripli on would be 70 10 85 perce nl o f the peak ac hieved on the le st (i.e .. HR maJ: howeve r an equ a ll y e ffecti ve a lt ern ati ve " Quid be 65 to 80 percen t o f H R on~~' Understand ing that a neg3 ti\ e test does no t mean the pati cllI is d isc,lsc free and that \ ulnerab le p laques may ex isl. J com;erva ti ve pre scrip-
for res istance training incl ude ( I) exerc is ing large mu sc le g roups be fo re sma ll . (2) stress ing ex halatio n w ith exe rtion,
(3 ) avo id ing sustai ned ti ght gri p. (4) foc using on RPE I 1-13. (5 ) us ing s low cont rolled moveme nts. and (6) s topp ing exe r-
c ise wi th any warning of co ncern ing or uncomfo rtabl e s igns o r sy m plOm s. 7Q The A rne ric;:m Heart Assoc iati on , A me rican Coll ege o f S pOI1 :" Medic ine , a nd the AAC YPR all ad vocate the im pol1ance of muscu lar fitn ess fo r the patient w ith cardiac il11pa imle nl and SuppOfl the incl us ion o f re~ iMa n ce Iraining into the patie nt 'S exe rc i1:>e prog ram ,75.7Q-81
li on rna) be a w j"cr choice.
Revascularization positive Exercise Tolerance Test If :I pat ient
h 3~
had a { )OXifi\'e
Err. the exerc ise
prescr ip-
tion becomes re la tive ly ~ impl e: durin g ae ro b ic train in g . it IS impo rt ant to "'- eep MYo~ be lo w the pa tie nt ' s i ~che mi c M Vo. Reme mber that - a cl ini ca l meas ure of MV0 1 is the product o f H R and SBP. kn ow n a s the rate pre~sure produc t ( RPP = H R X SBP). T he importa nc e of conside r ing the ische mi c th res ho ld is the recognit io n that BP \I. ill \ary d uring use o f d iffe re nt p ieces of e xe rci:-.e eq uipment 0\\ ing in part 10 the difference s in m uscle recruit men t. If the re is a difference in BP fo r a g ive n HR. then Ihe re \~i ll be a d ifference in the M Yo, to the pallen!. For e.\a m p le. if a pat ient has a HR of 100 bp m and a BP of 1",,0/80 mm Hg w h ile exerci s ing o n the
treadmill. and a HR of 100 bpm and a BP of 160/80 mm Hg \l. hile exercis ing o n the stat iona ry bi cyc le , the bicycle is costing the m yocardi u m more e nergy th an the rreadmlll , e\ en though HR is th e same. Dependin g on the patient '!> isc hem ic thres ho ld . il i~ pos!> ib le tha t an g ina rna) occur on the b i c~c1e but nOI o n the tre ad mi ll. A good Safe f) rip I!> to not e).ceed 90 perce nt o f t h~ I ~chemlc RPP. T he re ma inde r of the exe rc ise presc rip lion lJla) follO\, Ihe com mo n g ui de line s fo r aerob ic tralnmg In regard 10 freq ue ncy. in t e n ~i t y . and d ura tio n for parrent'l \\. uh ...'ardiac invoh e men l.
Strength Training The inclU SIon of ...treng th trai ni ng in a card iac rehab program I!> a rdall\ely rece nt add il1 0 n 10 the traditi onal c ardiac rehabilitallon program. 77 Ini li:Ji concern wa'\ thai re \ l~tOftuniiti fl'llleml'k;'f 111.. 1 .in
I
I 1Il1h~ nl)lIll.I.IIdIl~t:
ot ,Ipplo 'r""I~'h" hI 7'" '''' r..."nl dO(:. I)N nU:~1l " .. lIn~ I I llillo.llon J II mph.: .. 1',,11\.111 \-\lIhtl\J1 It\.".111 UI"- "'" m.. ~ k) .. L\ 11)\ pI 111'1) 1111 oJ .. ~ \11 (l(l ltd .mJ
t, ..
\I,'\JhJ IlldetOIC
'IIoHI~
h.l\"
OJ
111)1111.11 1 ( ,It
(-'..1
rocll..(.'O\ .t I'..aUI."III
\SI,\JiL J) hlllLlh~tI Tllol'
h"H' .I 1 11 )\ 1)1 l{1U Illl And CI ~ \ ot ~lt 1111 Jhd ~uuld hd (' .In 1 I 01 II'\(o'HlH r.l c: ... t'il!"-f,1 \.'ollh lill1,h,.Ilh. d\ ,Iull~ In)f nil hi t a\ \' .. l\ f',fJ III CI Hll.ulJ ti \ \ u mi 1,'1 "n I J vt 77 ''''-I~\'·ht
Nlh.)U),:Q ~Hhi.:1 ttll:'
t!lll,-
pr~
!'t.
IIwlldf, """I) 10 tI,~
dJlIc.·lI~ pr\l~ ~Il,
J\ ... 1UI I( II, Ilia lK' J,y;.,,,,- pr''''40:'. I,i, the
"'loll ... ,)( (lIJ .... h'la, l.omp.'n(lII
(It tx.tlh J~ IUlldK'lh 1II..,;i~
623
coexisl.RJ Besides coronary disease. alcohol. vira l or bacterial infections, chronic hypertension. and valvu lar dysfunction, cardiomyopathy may also result from an unknown (idiopathic) ca use. II is important to note that cardiomyopathy may occur at any age and is nOI an exclusive di sease of Ihe elderl y.
A common cla uh • •,
pe.npl'lC'nli
""-1..'01 J(1f\illlOO 10
.... ,.. .1 ....l.'d \,;vn tt.h.(llH~
624
Physkal Rehabilitation . f Pa . ·th O· seases of the Heart Table 16.10 Functional CI••••. 6catJons 0 t.ents w. •
4.CH;.0 callmin
Class I
Patients with cardiac disease but without resulting limi· tatlons of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea, or anginal pain.
4.5 METs
3.CJ-4 .0 callmin
Class II
Patients with cardiac disease resulting in slight lim ita· tion of physical activity. They are comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea. or anginal pain.
3.0 METs
2.0--3.0 call min
Class III
Patients with cardiac disease resulting in marked lim;· tation of physical activity. They are comfortable at rest. Less than ordinary physical activity causes fatigue , palpitation. dyspnea, or anginal pain.
! Class IV
1.5 METs
1.0--2.0 call min
I
I
I I
l ________________
Patients with ca rdiac disease resulting in inability to carry on any physical activity without discomfort Symptoms of cardiac insufficiency or of the anginal syndrome may be present even at rest. If any physical activity is undertaken. __________________________________ discomfort is increased.
~~~~~~~
~
Fou r-level classification system based on tunctionallimitations. Repnnled by perrrllssion of lhe American Heart Association, New York.
;Ul ath:' mrt to muintain CO. then: is a compensutory iJ1I.· n.' ;I~e in HR . A re~t in g lal'hycardia, th~reJore, may not bt' an uJlusual finJ ing. espel.'ialJ) for p;uients in Class III or 1\' hl'an f~l j lurt' . Bh'l()(i !low redistribution lX-CUrs in n."p. c~pecinlly that of mitral regurgitation. ma~ 41,0 be presenl 0\\ ing to lht' effcc i of the enlar~ed LV pulllllg on the l1liu-u1 valye. D>'pnel..l. either po!->ltlonaJ (onhopnl'a. p.lfoxy~mal nocturnal ) or exen ional. t,s Irequeml~ a"ocl3lcd \\ [th pulmona') edema. D)'!o,pne~t ma) al'" re,ult from the IIlcreu'cd entrgy CO,I of aL,ti vity;,u, J re~uh of dClrcJ\ed penpheral endumnce :Uld peripheral mu:.ek change\ Weight gain ulld pcnpht'nll cd~ ma are among tht" \Ifm. oj ~y Mem](: \olumc o\crluad. I m' r~J,ed me-rial rc,ist.IJKC rt'!lu lt, 111 an Iflcn.'i.I:-'t" III ,Ifterioad and therdorl' in MV()" The lflc reil~ed relil.,l"ncc n);l) re.,u ll lrolll it 1..(.llllblll.IIH1~ of fa('lOr." IIlcludtn g ( I) Inl..Tea,ed ~y lll palht't K ;.1(h ener '1(' ,W11ulat ion; (~J de" rCd'>C'o \ i.i \()d il..tlloll 01 \ ihCul4f .,llloOlh mu~de u\ a 1\· ... Ull 01 J dt'l:rc..t,e III th~ a\,ul.lhlilt) of Ihe cndll'hcllum -dL'n\~d ,dJ\,ulI Id('lur nun\. u\ ld", {~j all Ull'h.:a::.e 111 Ih~ t·nd0lhe li .d-d~ri\I;'J ~mlK)th ntu,..Jt: ',I~U(tJn .. tT1 l.. tUI , 1..' lItiolheltn - l . (~I ..In UI(It'i.I 't: III \a,\,.u14f ,tdlnC',)' a , ,1 fl· ... uh ut ,..til ami \\JIl'l rdellll()n ~ .JlJd j ~ I lhC' prt'-,{·'Il.'11 1. (JIll' ul till' l(\lIllHon tOnlplUllll ' t)II'.ltlC'IH' \\Ith C ill Uldl .lrt ; II I~ complt'\ and S) :-.temi c. Although the pre~lpilJllI1g l'au,t:' I' LV d)'!'ltum:lion. the ,equelat' of thl! thsea."tc prO\..e" imohes fJI more Ihan Ihe LV, 1Ill'luding 11l{~ J...ldncys, pl'ripherJ.1 \~l"'l'ular s)'s~ C HF
I.'
tell). ,~\deIJI
Illlhl' k ••lIld
Iwurohonnotl.d IIlfluC'nce~ .'~l
Ph armacological Manageme nt of CIIF \\ IIh (he ,Id\ l"1l 1 01 nl"\~ I1l1,~dlCJIIOn,
in the mJnagl'ment
01 ( I If", ')ud l a ... ullnhuled Jlph. freedom of move ment for ho urs. in whi c h the pat ient can go ~ h opp in g. 10 the movies, etc. Myop lasty l ~ a surg ica l procedu re in whi c h an e nl arged LV undergoe~ d ~ I ze red uction by remov ing di lated , scarred myocardIUm th at I ~ Ind fec ll W in contributi ng 10 co ntrau d lly. A oe", c l as~ 01 pace mdke l. the bl\ elllTiCular pace r, IS. bein g u..ed lor th~ more il1\ol ved C HF populatiun with an Inl ravenl ncu lar cond uclJ on dd ay (e.g., l ~ fI bundlt: brunch
Exercise Prescription Exercise programs for patients with CHF are relatively rece nt. Patie nt s whose cardiac statu s was once thought to be 100 fra gile to partic ipate in organized exercise are now no t o nl y parti c ipatin g, but exerc ise is recommended as an integral component of th eir medical management. 103-106 Studies have shown th at patients with heart fai lure can exe rc ise safe ly and reg ular exerc ise may improve functi o na l statu s, quaJit y o f life, exe rci se capacity and dec rease s ymptom s.I 07- 113 (See Evidence Summary Box
16.3.) The safe ty and im portance of stre ngth training and pe riph e ra l adaptatio ns have a lso been studied. lI~, II S Usin g a multid isc iplinary a pproac h that inc ludes a thoro ugh ph ysical examin ati o n befo re each exercise session w ith a review of sym pto ms and medications. low-level exercise may begi n if the pati ent is hemod ynamically stable. C HF i1) a mult isystem d isease th at affects not just the hen ri but pe riphera l mu sc le a nd art eries as well. Studies have de mo nstrated mu scle ti be r atrophy of sk.eletal and n: ~ p lr3tory m uscle, as well as an alteratio n in aneriaJ va~odil at io n capacit y. Exe rc ise ha s bee n shown to limit so me of th ese adve rse c hanges; therefore , an exercise progra m shou ld co nsider nm o nl y sys te mic conditioning. bu t also pe ripheral end urance training. low-level resiSIance trai l1lll g. an d res piratory mu scle trainingy 6- l lIl Oxygen Mtlura ti on via pulse ox imelry is a valuable tool in mo nilonng adeq uate ti ~!tue oxygenation. Patients may
Evide nce Summary Box 16.3 S tudies Investigating the Effect of Exercise on Patients with CHF. Reference
Subjects
Design
Intervention
Duration
Wle1enga, RP, et a l'°~ t999
N = 80 Characteristics:
RCT Location:
12 weeks
Male' Age: 40--75 ::!: 566 ::!: 8.3 years), Class II- III; EF. < 40',.; (26.5 :!: 9) Va, < 20 ml 0,lkglmin
outpatient chnic
Inlenslty: RHR + (60% of HRmax RHR): Frequency: 3 Xlweek:
N = 25
RCT Location; patients in reSidence
Intensity: 70--80% HR max: > 70% peak \;° 2 Frequency: daily; 4 x lweek Modality/duration: walk! daily 1 hour bid Cycle/45 min x 4 weeks
8 weeks
N = 134 Characteristics:
RCT Location:
Class I-III; Age : 60.5 := 8.6 years44--n; EF: 25.0 ::!: 8.9%9-ease, patie nt and family educa li.on develop s •'110" ' ng (1 CO ntllluum, de pe ndlllg on t he p'lIlent 's b I' • . ase me stat us and readiness to attend to the Inform ation . The Ph y~lca . I the rapist ' along wtt . h other illtlllbCf5 of Ihe he'd IrI1 care team must" to delenmne the , patient '!) and f 4 Ib) over short duration (1-2 days) • Decreased (or fa ilure to increase) SBP during exercise • Resting or abnormal exercise shortness-ofbreath
• RPE • SBP response to exertion • Symptoms
I I'--------------------------------------------------------------Pacemakers or • Pacem aker type and • RPE AICDs
method of function • Symptoms similar to pacemaker insertion • AICD threshold discharge rate • Ectopy or ventricular tachycardia
Heart transplant
• Delayed and attenuated exercise HR response • Elevated resting HR • Signs of rejection • Infection • Medica tion side eHeets
-. - ------
• HR (if available from postinsertion GXTj • HR and intensity threshold for exercise-induced ventricular tachycardia • Ventricular ectopy pattern(sj • RPE • Signs and symptoms
Adapted from American COllege of Sports Medlcme: GUidelines lor Exercise Testing and TraIning ed 5, Williams & Wilkins , Baltm1Ore, 1995 , p 191 . with permission. ' ,
633
63-1
Ph,·",jcal Rehabililation
Table 16.12 Pacemaker C lass ification S) stcm
m."(,'ckd fo r
J
1111.)11'
h(' a rt - hea lth ~ diet. Mos_t commonty,
p.ltll'nt" \, Ith coronar) h("~ rt disease ,arc lnstl1JC1ed., reduce t;.lt Ill t.lKe: ra ll e nt ~ WIth C I·IF are InStructed to rrtQt.
Hor "'J lt .tIld OuuJ 100Uk.C.
0 A
none atna
none
0 A
0
none
1\\L>·dications
R - ra te responsIVe
p;l IIL'nh rt:CC I\C wri lh' lt IIl format ion regarding the
InhIbI t
alrla
trigger
V ventncle
V ventrtcle
T
D dual chamber
D dual chamber
D - capacity to both Inhibi t and tngger
antl-infl arnmJloJ) medications they ~hould avoid becau5t of pO . . ~l hl c intcr... c t l On ~ wi th prc.' sc ripti on drugs. Patienl$ ,,11t1l.1ld :11 ' 0 he e ncourage d 10 di ~cl o.:;c all herbal remedks
-"
Pacemakers are commonly Identified by a three-leiter cooe as displayed In Ihe flfsllhree columns Pacemakers may also have The capacity to respond 10 physIOlogiC stimuli 10 Increase rale (column 4) and 10 overnde alnal tachycardia A fifth column lor anl ltachycar· dl3c Juncllon, IS rarely used due to the Increased sophlsllcallon of the newer Implantable defibrillators/pacema kers which renders this tunctlon unnecessary Example ' VVt pacer Will provIde an eleclncal Impulse to the ventncle if It senses tha t there IS no ventricular activIty wlth,n an appropriate lime frame. If there IS IntnnslC ventncular electncal actiVi ty, the pa cema ker w,lI be Inhibited.
Activit), Guidelines Palle nh (a nd famil )} ncC!d 10 be J bl c to und e r~ t :lI1d ... pec ific activlI), guidelinc&. whli.'h include planned ex e rc i'lc ~C'l ~Ion..,
a.., \0\(' 11
:l. ~
I('i . . ure lime J nd
desirtd
ac llon 01 thclr Il1 cJi c:.\ti ~n ~ . potc ~tial side effects. dosagt, ~lIlc...l tim ing o f medu:alton .... Pallents should also know \\ hu: h nonpn>c ription drug ~ s lich as cold , ~inus. al1trgy,or
rc~ t ..,.
a nd .., uppk'mcn t) tha i Ihey may be Hiking.
Lifestyle Issues Man y fador::- influence whether a patient wil l return towOlt after a cardiac ('vent. Many patients with CAD return 10 \\ ork if they we re employed before their event; patients with C HF arc , in general.. an older population when compared 10 pJl ienh with CAD and the re fore may have already rttin:d R e~ ul11 pl ion of sexual ac ti vit y may be an uncomfonable Ji . . (: lI ~\ i o n for ~ o m e pati ents. The re may be many issues of co nCC rn for the patie nt (e.g., fear, anxiety, perfonnancr con L'em~. lack of li bido). Patie nts and their partners are encourag ed to verba lize thcir concern s to each other and 10 sec k app ropriatc info rm ation from their health care leam.
So me medi cati ons (e .g .. beta-b loc kers) may blunt the se, ·
Self-Monitoring Pmie nt '\ mJ) monl lor the intensity of their activiry in a vari of . .\ ays: two of the marc comlllon w a y~ are palpatin g a pu l. . e and RPE. Becau. . e m:Ul ) older pati ents ha\'e dec reased ...en':)i !;v ;I Y in their palpation skills, th e lI ~C of RPE may be ea~ie r and more re liable. Th o~e pi.l1i e nt ~ that arc abl e to take a pu l ~ or choose to inve~ t in a HR monitor may prefer to u ~e Iho..,e method':). Se ll -moni toring not onl y invo l ve~ HR or RPE, bUI awarene':) ... of other symptonh or signs that may o; uggesl exe rcise in wlerance, such as Ji ghlheadedne':)s. menIal confusion, dy':)pnea. ~lIl d inabilit y to carry on a brief con\'e r~ at io n \"hi le pe rf0 n11ing an acti vit). Patienls with CHF commonl) u!-.e the d) !-. pn ~a !')cale and the Borg RPE scale.
el )
ual rc~ po n ~e , and it is importanllhat palients communicatr th is with their physician. Often, another medication or eal· ego ry of med ica ti on may be better tolerated. Whrn pat ients feel re ady fo r Oiiex, th e ir e nergy level throughout the day is satisfY in g fo r th em and they are able to walk out· doors a nd cl imb sta irs comfo rtably. they are probably ready for se xual acti vity. It ma y be helpful for patients to re member Iha t sexual acti vit y is not unlike other physical acti vity w ilh respect to e ne rgy cost, and therefore plan-
ning, pac ing. and warmup are powerful contributors for a more co mfon ablc Ou tcome. I"n some cases, the physician may recommend taking a prophylactic njtroglycerin prior to sex ual acti\'it y,
Symptom Recognition and Response
Psychological/ Soeiallssues
Bell1g able 10 recogni ze their spec iti c cardiac sym pt om ~ and to know how to respond i ~ J hey C'omponcm in pmient ed ucalton. Palient s should have written informat ion regardIng the action they ') hould take whe n . . ymptoms occ ur, fo r e>":l mpl e, when 10 call thei r ph ys icia n ur go to the ho . . pital.
Cardiac di sease may not onl y crea te new emotional issues but also enhance some th at mig ht have existed before the cardi tlc event. Reas~ ure pa tie nts thal many of these issues art! nonnal sequelae of their event , Encourage them tasedguidance and cou nseling in whate ve r arena they reel ap propriate (health care, counseling, religion). Many stud ies have add re ssed the relationship of erno-tional de press ion fo llowing CABG .13I- I)J AllhO~gb deprc!'.!\ion is re pon ed to ex ist. there is difficulty in objeCP lively measurin g the direc t impact of CABG on su~ dcpre ~,,;jon . So me of th e diffi culty arises in the use of dep r" " ion sca les (Bec k o r C ES -D). grading criteria. die presurgical e moti onal Slatus. and gender. Burg et II
Angina is the mO .... 1 CO lllmon sy mptom associated wit h l'orOllary heart di sea\e, whi le we ight ga in (2 pou nds over I to 2 da) 'I), d y!\pn~a. LE ede ma . and IIlcreased pillow':) for ... I~cp ~ler~l~ In 'k hlo.1ul RC ,, !( , .tll\k"r R\' ,Iod 1 '''I.xJ t1 •• ~ Cuiar Pt!~)lllklg.'-.a1Kc\ \h·\h,. S, t IlU". ~\IUI pI"''' 15 Oph'. l. "-klh.l.lU .. nh 11j ..:.uJI,k: ~ofllr3C{J,)f).mJ 1t'1.t.\ :&I1UIl III R'.tuO\I ...IJ f:./,rt',. D. d.llJ Llhb\ R ,,,hi: H ean~;lSt , Te\th(lot. 0 1 l.l.rdlu\..l.'-I.uJar 'lcdt, In.:'. cd 6 " B \.iunokN Phil,IJelphl" 14>1- p.l41 III Or ... ull .... JIJ. l:. . \,)rtn.d JtKl .It-n.'IIIl.11 m ...",.lIdrall un.: l1oo. .t5a\· Illt'nl .,," CJ.1JI.j~ 1... n...I1,)(\. \" ... "'lX'r D.!rogen pl(l~ progeqm for .~econdary prevention of coronary he nrt di ... e" ~e 111 pc,., t mc nopau~~1 Wflmen. Heart and E...lroge n/progcqm Rcplacemc'lI Study ( HERS) Re
I'tll l.l ..k!pill,1 :!Ol.ll r hlkl Ak\.mJl'C R\\ . \., ,Ii '\ r~cgJllc.'nt d{·\a!il.IIIll\' .... u-JIJ.1 ml,d1. lh'lI (' 11111,',11 prl"\'ntaI1l1(l rJl.l ~n(l'11L '·\.JIU,II)"II .lIlt! IIk,Il~·.,1 IB.tn.t.:c· ml.:nt. III f U'h:r \ \ !n.uldt'r_ R\\ and {)·R'>\lrb.~- K 'c.'d" I tlur~I' I'Ik' H":J.rt t'll II \k . IUI'/lil( J".", T. J I', In'I.I •• I'~ ",I.if ullf,t,,-'I:,,..I I \111 ( ,1il ( .IIlIl, .1 ~l~ "I, ·"H. 'illl!
',)
(11'1l~'
~1J.t~UI':1I1 I,u I" "hlt
In )+ u IhL' Ali ldl ... ,til III: .,,1 \,~. "- 1.11 )"" .lI •.! l!'It' AU6c:'n\. .IIl ( u!lnc(llt ..I1 J.ul"1!:\' Ulul ••I.....1I III Nlt 1_1>(1 I'I'N ~ \\-CUtt:1 K ( .·.n ' .."'" IKdrt ,j."........ III .....!I,d\ 1 \, .1"" 1.. 11., .... 1 c:dlt~ w Jr"IH.lU,_ .. n. dt.tlt .. .. 11i lltill ••11 .. "h:_ In Ji.11 1"n r': J mJ 'tI. cnetr ~ j II .1 ,1 V. uHI(:Ii ,JII,I Ii, J.II 1J 1!>l .. \\': M ,,.., , \ \ot Lb ul tt)l.,l p..:h 4'J It(:m lL.,~·n ( II (to,,,.,;lh '11 ........~ K... I 11I1";f\.:IIII-I1I III J uil.lll Ol~ ill'll! \'. (I')!,CI ' k. h:d ) \\ 'IU"II .. lid 11l .:n \) 1'(,'.1-.(: l \ ( lilt' pr\J It- ~~ liwllll "
50. US Preventative Serv icc .. TaJ/II ..lh'JJ \)I(I ' K .... , I'l,~h .. alh>ll '111 t'lf'
' .1
f" 1,....·1 I>.N~
III 11~.tl\ In ,1\' ..1 It! ,.1 l.I',lpl..l .... uJ.d .. lit! i'uhu,IIl...l(. k l n,tbd ll,JII •• U 1'111-,;1 011 t.. " ,Urloll •.-U" Kh lo. SU.llt " . IIIt.n
640
Phyoical Rehabilitation 97. Yall . AT. Bmdlcy. TD. and LIU. PP: The role of Continuov, . airwa) pre~~lI r¢ m the IrcatmCfl! of congest1\'e htan fail ~
\ 1f'lllloring In Gutdt·hnc..' for CUrdlat Rehubi lilatioo Programs. AACVPR. cd:. Human KmCllcs. Champ.tign. fLo 1995. P 7. 7.\ Borg. G Borg '~ Pert'CI\ed C...enion and PIlin S("ah:!l. Human
C'hamf':ugn. IL. 1998 ; J L('nne. SA, an.! Lew. n, B. AmKh:ur trealme01 of acote coronar), lhn\mb0~I ~ JAM>\. 1 ~48 · 1."\;fI . 1952. i5 Am('ncAA A"ocblhm of CanhQ\.I"Cular lind Pulmonary Rt'hllbllitllllNl Phase. ofCnnhac RchatHIuation. In Guidc:l lllC.':i for
CanjuJC Rchubthtawm Pn.'gnun~ Human Kinetic!!>. Champaign.
lL. ICI95. P -IQ. 76 4.mcri...an A"c)("iHlioo llj 8rJlm3!'oCuiar and Pulmonary Rehabilltalion pallen! f:.duclllion. P,)..:.hological h wclii and Outcromc... In GUloclines for C'ardJaC Rehahlhlal100 PrO~r.tIllS . .\:\C \ ' PR cod:! Human KmclIcs. Champaign. IL. 1995. P 57. 77. r>kCanne\. , . Rolt' of rc'I~lance trauHflS. In hean dl~3'-t· . Med S~I Sron:-' [\crc S'96, 1Q98. 78 BClUamml . Y. el :II : Effects (If high in ten~il~ strenglh tr:lI nmg (In qllilJJI~ (11 life p:tr.)mcler. m cardIac rchabdillilion palle,,". Am J Can.hol 1\41. 1097 - Q Amenl' a.n A""lll:lation 01 CardHl\a-.clllar and PulfllUlldr) Rehablhl81lon ~ Graded f'\crr,--'-th. nJ q Wnk. Brov.lI. BoMun. 194~. p 15.'~ )S7 \":hlaJll. Re, and S,onnenhhdc EH P';lI.hl'lmY\loklit) ••1 he an 1"'11 ure In Air Kinder, R" , "ilhl.lIl1. Rc' "'u ~l~ r. V Icd,) Il tll'\t'~ Ilu· Hean. ed II \i.,..mcnt of PUlmonal) ~ rCilcllVlly III hc:\n frlliure. Coo gc~ 1 Hcan F;tll 993:176.2003 102 Salulhc. T V. Dllnop0ulo... K . .Ind Francl~ . D' Card,ac 1't5~tJm. IlI/Htlon may rcdul~C' all"au.lh,l!m' ..
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Br.. u:,,,,,IJ. r 0:1 "I tell .. , HI .'un ...... I.titial Iluid. remov ing excess nuid, blood waste. and protein mol ec ul es in the process of nuid exchange, Lym. phatirs are locat ed in all portions of the bod y except the central nervous system and comea.2 The lymphatic system includes lymph vessels (superficial. inlem1ediate. and deep. also referred to as lymphatics): lymph Ouid: and lymph tissues and organs (lymph nodes, LOnsils. spleen. thymus. and the thoracic duct). Lymph Ouid is first absorbed at the capillary level, then channeled through small vesse ls call ed precol/eclOrs, and finall y picked up by the larger. valved vessels called eo/. lectors. The collectors have contractile. smooth muscle. and val ves. Lymphatics are eve n thinner and more likely to collapse unde r press ure than ve ins. 2-4 Lymph moves throu ghout the body by a number of mechanisms. Superfi· ciall y, lymph fluid is moved by the process of diffusion and filtrati on. Below the de rmi s. intrinsic contractions dri ve lymph propulsion in the deeper collectors. The force to generate a lymph vessel contracti on does not come from th e heart but from Jymphollgi olls. srnall pump·like segments within the larger lymph vessels. The human body is wonderfully equipped to provide a variety of stimuli that have an impact on Iymphangion contraction :+-8 Parasympathetic, sympathetic, and sensory Ilen e stimulation Contraction of muscles adjacent to a vessel Pulsation of arteries adj acent to a lymph vessel (even precapillary arteri oles have pulsation) Abdominal and th oracic cav ity press ure changes that occu r during brearhing Vollime changes wi thin each Iymphangion (internal receptors respond 10 tension and tri gge r a contraction) • M ild mechanical stimulatioll of derm al tiss ue increases th e frequ ency of Iymphangion contracti ons Excess lymph fluid is transported throu gh the thoracic duct and e mpti ed into th e venous angles at the left and ri ght jugul ar ve in tru nks. Under normal conditions. lymph flow i~ not adverse ly affec ted by gravity. Under abnormal cond itio ns, the lymphatic :\YMem Illay ex hibit excess lymph pooling re lated 10 gravity. especiall y in the lower extremiti e!) (LE~) .
Integumentary AI\o reh:rred to 3,\ an organ. this sy~ ICI1l b the most often '<en and touched by a physical thempi, t of all the body ,y't(;nh. The Integume ntary system has a fu nctional relatiore.hip 10 m.tny other bod) !)y-.tems. Tht! he . and lymphatic capi ll an c!i. (denllal clrc ub tion ). A
UlOrough rev iew of the functions of the skin ill uslnll c~ the importance of even a sma.1I area of damage to this orgtm. The d i sc u~~ i on on , kin analOm y. wit h d iagnuns. in Chapter 27 " 111 ~UppI C JllC Ill th is overview. The epit/ern/;s is aV;.Jllcul ar and ":Iter-resistant . It provides protec tio n from infecti on. abra' lnn . :md chcmil'a ls and ass b ts with hea l regulati on. rtlcnlion. and di !:lsiplllg~ dJld de nl! It:l-hIllLjUe... Cj tOto\l\. tvplL'o.1l Jgem'\l that kJJ hJ
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rden. to an) H1JUT) ur
Figure 17.2 Chronic wound.
inefficient ce llular activity. and lack of moi sture resulting in delayed or absent migration of keratinocytes. infection is caused by cross-contamination. improper use of gloves and othe r protective devices, inadequate use of sterile and cl e an tec hniqu e , lac k of pro per ha nd washing, lack of adherence to uni ve rsal precauti ons . and inadequate clean or ste rile technique. Sheer injuries (skin tears) can occ ur during transfers and repos it ioni ng . Isc hemia results fro m unrelieved pressure owing to inadequate turning sc hedu les o r absent or inadequate pressure relie\'ing ded ces (PRDs ). In gene ra l, the larger the wo und and more traumatic the c a u~ . the more likely a delay in healing rime,
Complications of Chronicity A c hro ni c wo und c real e ... a co mple x and seri ou ... health pro b le m for an in d iv idu a l ( Fi g. 17.2). C hroniC w ound ~ may lead to com p li cat lo n'1- includi ng an } o r a ll of the follow in g: i mpai rm e nt ~ of bod y tUll cli o n a nd ... tructure 'i, re~lri c ti on ... In 311 tV llle", and panH.·ipJliun. nt!ed for a ... , j,l,ted livi ng or home ~ \I, nh frr:~ucnt disruption o f wound through mappropn..th: dt'an">lIlg. u~ of IIldPpropndtt' dre ...... lng!> and dres!) lIlg ledullqu~~ , cy totoxIc IOpit'at dgenh that lead to
Figure 17.2 Chronic wound.
inefficient cellular activity, and lack of moisture resulting in delayed or absent migration of keratinocytes. Infection is ca used by cross-contamination. improper use of gloves and other protective devices, inadequate use of sterile and clean tec hnique, lack of prope r handwashing , lack of adherence to uni versal precautions, and inadequate clean or sterile technique. Sheer injuries (skin tears) can occ ur during transfers and repositioning. Ischemia res ults from unrelieved pressure owing to inadequate turning sched ules or absent or inadeq uate pressure relieving de\';ces (PRDsj. In gene ral, the larger the wound and more traumatic the cause. the more likely a delay in healing time.
Complications of Chronicity A chronic wo un d creates a co mpl ex and se riou s health
proble m for an individu al ( Fig . 17.2). Chronic wounds may lead 10 complication s including an) or all of the follow in g: impairments of body func tion and structures. res tricti ons in activities and participation. need for assisted living or home care , decreased (.jua lil) of life perceptions. depre:-.!>ion, infection. malnu triti on and weight lo!)s. protein depletion , ti ss. ue fibrosis. 1m, ... of limb. and death. E\ er) yea r o ver .') million Amencans are trea ted for chroOle \\ound~ at a CO, t of bi lljon ~ of dollars. Inak.ing this type of "ound o ne of' the mo~t co~tl} c halle n ge~ III health care. " A chromc INQund faib 10 heal bel.':.HhC of an underl)'ing Pdtholog} and " III not heal unlll th~ cause is corrected or imprO\~d The cl inician mu~ 1 uetenlllne the faclOTS contnbullng lO abnofllul "ounet heal ing and then develop an appropn..tl~ plan ot \.:are lPOe) to ove rcome or address the ()b~lat Ie .....
Chapter 17 Vascular, Lymphatic, and Integumentary Disorders
Vascular, Lymphatic, and Integumentary Disorders Arterial Insufficiency and Ulceration Arterial insufficiency refers to a lac k of adequate blood fl ow 10 a region or regions of the bod y. Many different disorders may arise frol11 arterial insufficiency and can be classified by a variety of descriptors. For the purposes of this chapter. references will be 10 art erial insufficiency owing 10 organic disruption of blood fl ow to the extremirjes or to peripheral \'ascular di sease (PVD). PVD is a 2eneral term used to de scri be any di sorder that interferes : 'ilh arterial or venous blood flow of the extremities. Factors that lead to PYD owing to arterial insuffi cie ncy include smoking. cardiac di sease. diabetes. hypertension, renal di sease. and elevated choles terol and trigl ycerides. Obesi ty and a sedentary lifestyle are related contributors in the cycle of di sease and vesse l obs truction. The dam age caused by these fac tors is refl ected in stru ctural changes in th e wall s of the arteri es. causi ng abnorm al blood fl ow. The fo llowi ng is a brief overview of these disorde rs: • Arteriosclerosis: thicken ing. hardeni ng. loss of elas ticit y of arteri al walls • Atherosclerosis: the most common fonn of anerioscleresis. associated with damage to the endoth el ial lining of the vesse ls and the fo nn ation of lipid deposits. eve ntuall y leading to plaque fonnation. • Arteriosclerosis obliterans: a peripheral manifes tatio n of atherosclerosis charac terized by intemlittent claud ication. re~t pain. trophic cha nges. This is the arterial dL~e ion and tissue isc hemia. especiall) III )ou ng men "' ho ~rnoke . • Ra.vnaud 's disease: a functional va.."omOlor di se a~e of small anene,> and 'U1enolt:s, not liJ...ely to c au~e i~chernic n ecro:,) l ~
• Ukenulon ' l.:I periphe ral ~ lgn of a long -'> tanding dl ~ea')(.' proce ... ~ : h) deli nHinn . aTleTll:I1 ulcer... :.Ire a ~:')oc i a tc d \\ Ith ant:Tlal In~uHiLle n q Betv,tcn I() ;U1d 2" peru~ nt of LE uker'> are l:au:-.I.!d b) anenal UI ')t:' : Id tC'fa l mall~·~111. dor)unI 01 kt'l 111\· ...
651
• When wounds are present on an isc hemic limb, athero~c1erotic occlusion of the peripheral vasculature is almost always present. • The majority of patients with arterial insufficiency also have diabeles. • Trophic changes are present and include abnonnal nail growlh. decreased leg and foot hair, dry skin. • Sk in is cool upon palpation. • Wound s are painful and patient may also describe pain in Ihe legs and/or feet (see di sc ussion below about intermillent claudica ti on). Wound base is necrotic and pale, lac king granulation tissue. • Skin aro und the wound ma y be black. gangreno us, mummified (dry gangrene). • Othe r signs o f arterial insufficie ncy will be evide nt: decreased pul ses. pallor on elevation. and rubor when dependent. History Painfu l cramping or achi ng of the LEs during walking is the most common complaint in patients with chronic arteriaJ occlusion of me LEs. The pain is caused by intermittell1 claudication lhat occ urs when exercising muscles are not receiving the blood perfusion needed for nonnal fu nction. Patients should be exami.ned for other sig ns of arterial insufficiency if intennittent claudication is occ urring. Rest pai n th at develops at night. awakens the patient. or requires analgesics for relief is considered more severe than claudication. The individual with vasc uJar dysfunction may also be diabetic. Diabetes will contribute to slower hea..ling times and difficult y fighting infection. A wound in a distal. ischemic area is not likely to heal unl ess the vascu lar su pply is enhanced or restored. lndividuaJs with anerial disease and diabetes are more likely to have hypertension. may have previous bypass grafrs or amputations of the toes. pain on ambulation or rest. pain with elevation. cold hands and feer, and color ch:Ulges of fingers and toes. Owing to the long latency ~riod between injury 10 the anerial (,lrcularion and c1mical appearance of disorders. healthcare providers, fe of ..,e('ond.u~ l~mphedt"mJ \..... urgt.'r~ and/or radIation therapy ih pm 01 hrea't CJncer Irt>Jlnlcnt. The n~e in in(,ld(~n;.'(" ()f mha I~ pc-.. of can;.'er .md the ~ub",equel1l (redl1lll'"1l! .. Il)r th o~ ~..1ncer., h.l.... lead to an U1('fe~ III repon, l)1 I~ mrhcJe-nl,J tolhm Ill!! tre-3lrnent lor CJncer of the pn.hIJtt". hIJJde-r. ulcru ... 0\ ane .. , JnJ .. !....n. Canl".·er I") not tht.' onl~ ~..!\J ... ~lI\e IJ.:lor I\)r l)mphed~nu. II I') common t...)r .in 1111.11\ ltiu.J1 "dih C\ I to de\ fd op I~ mphedemJ. (ng-
:;t'J't.'J b) h)ng,unJlIlg IlUid (,1\ eril).td In (h~ LE.... e;.:\)uJ.1f\ I~ mrht:t.km.t C.l.Il .iI .... ' ~ Ingger. . .d h) the I,.'omplt· 1".".1lJnn, l)J p..ir.tl~'h ..1"u,,-, 10 ~hIllllJ;. re~H.ln,11 P.J1Il ,>~n~ dWUk', \,1J H.Wm.l
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History A pati e nt hi story consistent with lymphatic system damage o r defonnity will be pivotal in the diagnos is of lymphedema. A patient 's history might include cancer. cance r treatment. radiation therapy. lymph node disruption. CV I. trauma. surgery. or (in primaI') lymphedema) onset o f s'Wc lhng at birth o r puberty. There may be a long lale ncy period bet\\cen injury to the lymphatics and clinica l manifestations: t hu~ he-alth ca re providers and patient . . must ad here to pre\enlioll gu ide-lines and be sus· plciou,,> of 3n~ .... igns and "i) mplOms that might lOugge~t l}rnphcdema . Chronic mnammatlOn of II bod) region rna) e\entuJII} lead to I) mphedema. L~mphedema can de\elop \\lIhln a rev. "ee ....... of tn .... ult or as long. 35 30 ) ear... laler.
Tests a nd \l eas uremen ls The dlJgno",h O [ I~mphedem .. can be made -wilhoUI tht u:-.e of ')f\'t:l"IJ.1 1I:.... h klr mn,t mJI\. tdual... pOsHc-nt hl!tWl)" ",-lml..,!ent \\.uh I)mph ')) ... t('m tLtmagc or deformH). a't)'>[c-nh re\ Ie" olttcn;,·illJ.ti J'~lgnt.l''''o m",pecuoo, and pa1p:tthIn '-It the lfih:~umcnt ..tnJ girth lTk"d.,uremcnh are iJIL.k4 11 ;Jh: h.•r l lc ... k.in IiKft:ll'>t:d ~u\Ct!pllblllt > 10 ~kin breu \...dQ\\ n and IIljury Prolkn'JlI> tor heavy callu ... formallon Dy~va ...("uluf ... ymplfJm ~. II pre"'t:IlI: - Usually .trkrial dl~o rd er ... but can be cumpllcated by reduL~d curd lw..: lunclion frulll autonotlllC Ci.HIM~~
Du ri ng the exa m ina tion. every pa tient w ith d iabetes should be checked, using mo nofil ame nts. for the prese nce of pro tective sensa tion in the LEs. Thi s sho uld be part of a system s rev iew fo r pati ents with di abetes even whe n diabetes is not the primary diagnosis. Data o n skin tem perature of the L Es sho uld also be recorded during the exam inatio n. Info rm ation about blood glucose levels sho uld be obtai ned as pan of the examination and m ust be considered for safe developme nt of the POe.
Intervention Physica l therapists are in an ideal posit ion to provide education and com pre hens ive foot care interventi o n fo r the diabetic popul at io n. According to a rece fl( National Di abetes Fact Sheet. com prehe nsive foot care programs can reduce amputatio n rates by 45 to 85 percent. 79 In add ition to appro priate wo und care, and mainte nance of acceptable blood g luco se le ve ls, inte rvent ion mu st include som e method of decreasing we ightbearing SLTesses. Options fo r off- loadin g inc lude cru tches or wa lke r. c hanges in gait patt e rn s. walking ca sts o r splints , a nd specialized foot wear. It wo ul d no t be unusual to ut il ize a ll of the offloading o ptions o ver the c o urse of treatme nt fo r a foot ulce rati o n. Interve ntio n mu st inc lu de a compre hens ive prog ram includin g e le m e nt s of wo und c are . foot care . ed uca tion. PROs. o rth o ti cs, exe rcise. and modalities . Eve ry e lTo ri sho uld be made by c lini c ians and pat ients alike to improve o r retain skin integrit y of the fool. Refer 10 Appendi x B for patient educat ion info mlation on foot care. In additio n to o the r medica l co mplications of diabe t e~, aJtered circul atio n 10 the foot can complicate sympIO m s f ro m di a be tic ne uropath y. Interventio n s ho uld address the wo rst pro bl em first but w ith lower expec lat ion~ fo r hea ling when vasc ul ar disorde rs coex ist with neuropath y. The fi ve most commo n di sorde rs of the vilscular. lymphatic, a nd integumen tary sys te m s have been d iscussed. Disorde rs cause.d by surgery, tra uma, malignancy. hematologic diseal\e , con nec tive tbsue di sl!ase. and lhe nna! injury lI'i/l impact the ~y~l t.'m~ discussed in thi s c hapte r. Owing 10 ~pacc re~ t ri(,; t ion~. howeve r. Lhey w ill no t be discu ssed itt thi~ ti me. Interes ted readers sho uld see k one of the
658
Physical Rehabilitation
texis mentioned in the reference Ji st 10 supplement information presen ted here. Examination and trea tm e nt of ot her di sorders would utili ze the same lests and meas urement s and treatment interve ntion s di sc ussed in Ihi s chapte r based 011 the patient's unique c haracte ri sti cs.
Patient~ageD1ent
Examination History A thorough history will include seeking infomlation on systems beyond the local affected area. As noted in Chapter 1 of this text. physicaJ therapy exam inati ons for a ll d isorders begin with gathe ring data from the patjent. family, and other involved individua ls. For th e di sorde rs di sc ussed in thi s c hapler. infomlation needed fro m the hi story will be similar. Many of the disorders discussed in this chapter have a slow
or insidious onset, making hi slOry taking challenging but important. Refer to Chapter I to review the type of data that may be: generated from taking a thorough history.
Systems Review It might be tempting to skip a systems review before using other tests and measurements in the examin ation process to save time. This step. however. is of ulmost importance as physical therapists move toward greater autonomy. Results melY alert the physicaJ therapist 10 problems that may require referra1 to another practitioner. A systems rev iew is particularly important here because the disorders discussed in this chapter ~ the result of dys fu nction in other systems of the bod y. For example. diabetes may lead to wounds of the feet. breast cancer surgery may lead to lymphedema, heart disease may lead to arteria l wounds of the legs. and paralysis rna) lead to pressure ulcers. A comprehensive approach to ob~f\in g and examining t.he patient will .:;et the stage for the imcMlgatlon and daLa collection that follows.
Tests and Measurements 0" mg to the ~Io-.e rrlat lon~h ip among di '}orde ~ of the
Va5-
cular, lymphatic, and int eg um t' ntary ~y~ t e m ', the irnpor· lanl'e 01 dilTeremial dHlgno~I~. and the h"-ehhood 01 a p;:uiem ur diem pre~llung v. nh more than one di..on:kr, a ph) ~ ica l thempl... t v. III make- U'lI.! of a "Ide vanety of avail able ' esb and mca ... urt.'menh dUring the exan lillill lon . "1l1C le.., t:.. and measurements dl...cu ... ..,eJ In 1 11I ~ dl J pler .Ire d("-.cri~J U1 Iht." order III "hit h the), ~II C p l ...• .... (' lll ed in Ih(' (iuuh' [II Pin \/1111 lit, Il/ptH PW llII I 1I1)' landmarks are in tZlk.ing girth measurements. the ... tandJrd ilIl10J1!! t"\pen \ vO" ho treat c:licllla is ro lbt 4.'on"'hh:.'l1Il:l'nllm~ t l·r ifHt'f\db IIb l~aJ , For ~'\al1lple. in nlea.~u( Ing tht! LE. ·.:II\.' lImtt'r~ IlI I.l 1 mt'ds ure mentl!. an: taken every 1l'111 .... t rt'prt~ ..,e lll.itHln 01 ~x1, Jllu.:-n . . lune lf-l'are compo ne nl of the tre atme nl in o rde r to re ta in the gain ~ made d urin g inte rve nti o n . Most of thi s into mlation (:all be o btained Ihrough interviews and obserViII ions . Add itiona l lOo l ~ wou ld inc lude cog ni tive and beh:Jvlo r bcales. s~l fe t y c hec kli sts. and leaming profiles. Assistive a nd Ada pl i,'e De,"ic\'s It i . . ver) li ke'ly that pa ti emb v.,i th vascu lar. lymphatic. o r IIltcgume nHU) ' I.h~orde;: n. will need ass isrive devices during Ihe: IIlterve ntio n Wid ')t:lf-care phast;s, o f m,tnagement. Data Will mo... , often he obw.int:d by o bsc('\,nion. Pre~ure-se ns ing de\ Ices a lTer obJeC Il\e data and \'vi ll be di sc ussed under fe ... t!:l and M e~url?m~nl s. for Imegume mJI} Lnlegrity.
660
Physical Rehabilitatio n
Figure 17.13 ASI test.
Figure 17.12 Skin temperature exami nation using a skin themlOmeter.
Circulation Collecting data about the movement of blood and lymph throug.h the arteri al. ve no us. and lymph atic system s is interrelated with the te sts and measurement s fo r integu men ta ry integrity. Tes ts and measurement s for skin changes th at may occu r with impainnent of the c irculation are di sc ussed unde r th e section on Int egum entary Integrit y. The presence or ri sk of pathology o f the circula tory systems can be detected in many cases by skill ed observation and palpation (e.g .. temperature and pulses).
Temperature. Tempe rature can be ex amined by palpation. Objec tive data ~hou l d al so be collected and quanti fied us mg a radiometer or a ,hermisror as superfic ial skin tem peratu re change& are o ften indi cat ive of pa lh o log) (Fig. 17.1:!J. A dec rea~e in &km tempe rat ure can indi ca te poor arlena l perfu:'JOn. An in c re a ~ e can indi cate infection or actI ve di :,e a ~e proce.,~ e ~ ~ u c h l· I'> IIldl u t1ed. r·or the indJvidual with lI11p.J.JreJ "CI'I'Jlllln 01 the k \:!1. e.uw depth ~hoe .. ma) be
66J
indicated. Existi ng shoes sho uld be checked periodica lly fo r fit and wear. A referral 10 anOlher profess ional for protec ti ve fool wear ma y be needed. Compress ion garme nts and ba ndagi ng. considered support il'e devices. mu st be chec ked peri odicall y fo r fit and fun cti on to ensure they retai n the ir e ffect iveness. Gannents and bandages will be essen ti al interventi o n c ho ices fo r most ind ivi dual s with ede ma a nd lymphedema . In the late r stages. a pat ie nt 's need fo r dev ices may prov ide a way to quantify the remediat ion of im pai mle nls or funct ional limitati ons imposed by the sympto ms of the disorde r,
Pa in Owing to the high inc idence of como rbidit y in patie nts with d isorders of the vascul ar, lym phat ic. and integumentary systems. the measurement of pain may also assist in making a different ial diagnosis. The presence or abse nce of pai n. its loeatjo n and intensity. its effect o n sleep, and o ther qu a lit y of life factors (QoL). sho uld be measured (see C hapte r 28). Pai n sca les, dra win gs. and maps a re e ffective fo r doc umentation. Postu re Indications for exam inati on of pos[ure include pain, heavy limbs. scar ti ss ue. poor body image (e.g .. following cancer treatment). o besity. and decreased sensat ion. Data can be obtained with the com bi ned use of a posture grid. tape measure. o bservation. and palpatio n. ROM The need fo r adequate RO M cannot be underestimated . Follow ing ROM screening during the systems review, spec ifi c RO M measure ments are oft en ind icated. espec iall y wi th persons for who m move ment is an essent ial part of symptom management . Examples are numerous bu t include ankl e ROM for the person with CVI. shoulder ROM fo llowing breast cancer surgery. or knee RO M in the ind ividua l with lymphedema of the LE. A unive rsa l goniometer and a tape meas ure are the mini mum lOols required 10 obtain objective ROM data.
Self-Care and Home Ma nagement Funct ional limitations and disabi lity are common. E.xaminat ioll. educat ion, and trai ni ng that a llow the patien t 10 safe ly perfonn self-care and home management activities are of great importance in plann ing and implementing the self- management phase. Descriptions and quantifications are needed fo r documentation and goal sell ing. Exam inati on tools shou ld include funct ional measures of both basic (BADL) :md instrumenm l (IADl) ac tivities of daily living ( di~cu sse d in Chapter I I) as \\e ll as fall rhk scales.
Sensation lnfonnation from the hi ~tory and systems review may indicate the !leed fur a dl!ta iled examination of st:"nsory funcrion. Therapists should 110t rely 011 history alone as an indication for ~ n~ory te ~tillg. however, because many indi\'idua l~ arc unaware of the ir deficits until tested . Sensory tests
664
Physical Rehabilitation
are particularl y im portal1l when symptoms are long-stand ing, or include compl aints of numbness. ti ngling. or bu rning. Patients who should routinely be tested arc those who may receive LE compression treatments. and all individua ls who have a di agnosis of peripheral neuropath y. diabele!:> . and/or arteria1 di sease. In addi ti on to ohserval ion and palpation. initial t e s t ~ shou ld incl ude testin g for protecti ve SC Il ~ a ti on using fil am eJ1l ~ such as the Semmes WfinSleill n/ol1ofilamenrs. The fi laments are supplied in vary ing sizes and are each mounted on a hand le. The fil ament is appl ied to the skin un til it bends. The patient is asked to re port. wit h eyes closed . whether the fil am ent is touc hi ng th e body pa rt. Each monofi lament suppli es a specifi c amou nt of force when it is placed on the test 3rea and ge ntl y benl. Thc monofiiaments are avai lab le in a larg c se t bUI most tesling can be accompli shed using a few fi lame nts. An indi vidual has IIorma l sensarion when the 4 . 17 monofil ament (I g of force) can be felt . An individ ual has prorectil'e ull sarion intac t \V he n th e 5.07 fil am e nt ( l a g of
!:> wel1ing around the ankles. Initial data may be gathered by examini ng arteri al blood gases. observing the work of breathin g. o r utili zing a spi rometer. Additional appropriate tests include the airway clearance test and use of a pulse oximeter.
Evalua tion , Diagnosis, Prognosis Once the ex ami nat ion is complete. the ph ysical therapist evaluales the da ta and de te nn ines the di agnosis and prognosis. A s prc5.cnted in Chapt er I and outlined in the Guide to Phys ical Therapis f Practice ,80 the phys ical therapist needs to consider a num be r of fac tors including clinical fi ndin gs. ove rall ph ys ical fun cti on a nd health status, social suppo rt. mu lti syste m in vo lve me nt and comorbid cond itions. and chroni city. seve rity. and stabi lity of the condit ion. The next ste p is the design and implementation of the plan of ca re (POC) includin g procedu ra l interve nti ons.
force ) can be fe lt (Fi g. 17. 14 ). W ith loss o f pro tec tive sen -
sati on. th e indi vidual ca nnot sense trauma to th e foo t. oft en leadin g to foot ulcera tion . For th e indiv idu al who has lost protect!\ e se nsmi on. the use of special protecti ve footwear is indicated. Lac k of se nsat ion. e."pecially protective se nsati on can be a characte ri ::,tic of longstandin g diabetes. Decreased sensati on may signal a di sorde r ~ u c h :.1\ sclerod erma . To test for sharp/dull sen!:> atlon. vibratory ~e n s a l.i o n . pres~ ure and other se nsat ion:-.. toob for ga thering data include a pres::-. ure ::-.caJe. tuni ng fork . and/or ae..;thesiometer. For more infoml atio ll . the reader i ~ refe rred to C hapter 5 .
\ t nfilati on and Res pinltion Te "t, and J11i:~ a , ure"i should be u, ect 10 de lermllll' if th e pallent hJ ,) ad t:qulit e ve nt ila tio n ~l1ld re:-.p iration to mee t nor mal OX) gen dem;tnd ... Th e pre,c nc(' o f patho log j rrtlg lll be IIl d lc rtl ed fro m a predH':- lable ~ o ur ce ~ u c h i.1' hreath ,aund" or lhl! color of ll i.lllbcJ .... Patho log) could aho be Indicated h) a It:.... ~ prl'(lI (( produce J 'pra) n HlI.llner t h~ 1 dc !t\er, ~a l i ne or a ~urfa ctant at \t':r ) gentl e pln . . ure ... (Fig.. 17. 17), Infl.~c ted woulld~ can Jll,o bl' l'Ik ~ II \ t"'I~ l' l ca m~ d \0\ IIh nonforceful irrigalion . \\ound ... v. It!. nel nHIt,." tl ...... ue or dcbn .... ho \\·eve r. m"~ n:'ponJ '-".: , ' ((I ,I fl.' \I' '(' ...... IUlh 0 1 a more forceful I) pc of d ta'h ln ~ h l! \l.Il llIl J ... tha i Jrt.' d e an , \o\I lIh ne\\ tl~ ~ lIe gmy.l h. ,,:lej l)" l1l~ ~hu u l J oc unlle o nl) 10 remove e\I.:t!~~ cnJu~ t"llou, Ilt 11.." O f le ... lduc k ll h) drc'''' lIlg produl' .... .
Debridem"nt ddlllcd a ... Ihl..' rl' I1II..l\ .d o j forl.·i~11 l'IIatcn.i1 .and "k.ld , ~I d..ln l .l~ l'd 1I ... ' Ut: Kl..'lllm·al 01 d\!\ Iwit/cd VI m k L"I!..'\-1 II 'lUI I'.ill Im p 0 11.1111 IIlte r\ Cnllon 10 pre'I..'nl "I I..ll lt lrol b.l ~ tu .II ~ III\O\ Ih l' Il Lll urage 110flliJi t:d lul.lf 4" 11\ 11) III 1111 \\OlJ I UJ hnL ~I1 J l' nlullLl' tilt' ntl (11' tl ... ...,lIt: Dthridt'ltlcllt
'·III . It ,111 1 \ " ·h ",/llIitlll ll·/ IIO\I..' ~ lit
667
Evidence Sum m ary Box 17.1 Outcome Stud ies Using We t-to-Dry (WTD ) Dressings as Part of Wound Care Reference
Subjech
llesign / lntenenlion
Dunuion
Results
('umm,- h,IILiwd \\ nil .J '\I.\ llpel !lO that the enz) me can pcneIriltL' tht' \\ llunc!
lIimurgery. Bio'>l'rgCT) U:-. a fOnll of \elec tive debridemenl I ....11 ... 0 I ckm.'d In .1' nlll f!(?{J[ t/i;/lridl!nlel1 / 1/l('ral'l (MDT), or lll"lggut or IU(\,11 1hemp}' (Fig 17. 19). Whil~ it h:t.) beell in lht' III Ihe \\ L' ... tern \\ orld lor ovt: r 150 "t w·s. its popUbUlI) t.lt'LiIlIL'J \\ Il h lhl' i.n h enl u r . and the ce ll s that fac ilitate wound hea ling all have measurable electrical c urre nts.I ~5 ES affects variou s ty pes of ce ll , and the ir l'd .hon ;'I \l.' dZi.l lht:nny CCJnIlIlU()U ~ !ohm! \1,.
.....-F.'·· ', .. .,,,' : ..
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Apligraftneonatal Nova rti s Pharma AG
Male foreskin
Venous leg ulcers
Dermagraft Smith & Nephew
Neonatal male foreskin
Chronic diabetic foot ulcers
Inlegracollagen Johnson & Johnson
Matrix with silicon layer
Dermal regeneration for treatment of severe burns
Transcyteneonatal Smith & Nephew
Fibroblast cells plus porcine dermal collagen
Full· thickness and partial -thickness burns
Oasis Cook Medical
Porcine -based product
Classified as an exotic dressing, not skin substitute, diabetic foot ulcers
Blobrane II Bertek Pharmaceuticals
Porcine·based product sil icon bonded to nylon
Partial-thickness burn wounds
ex udat e creat es a ge l substance th at helps to maintain a moi ~ t \\Qund e nviro nm en t w hil e absorbi ng exces s exu· dates. Becau:--e they are permea ble, alg inates do not pro\ ide a bamer agni nst bacteria . Conve rse ly, this characterI ~ IH: males them a n effect ive c ho ice whe n an infected \\ound can not be cove red w ith an occlu sive dress ing. 1\ 1 o~ t aiglll3te'l currently require a secondary dressin g to hold them in place. Seve ra l manufacturers are combining algmate .. \\ ilh o ther products. such as h ydrocolloids . to ma.\lmize their effectiveness. The re is growing interest in the u!,e of ~i l ve r in ad vance d dress ings lO com bin e th e antnnlcrobla! ac tion of ~ il ve r with the absorptive qual iti es of algll1ate". An exam ple of thi s type. of dress ing is S ILVERCEL ( John~on & Jo hn son Wo und Manage me nt. ETHICOl\. Inc. Somervi lle. NJ 08876 ). Sl..in Sub, (ilU tes Considered b) ..o me 10 be lOpical application s and by olh er" [0 Ik dre..,~;n gs, human ... kin equi vale nts. and bioengineered tl"' ~ lIe, are finding the ir pl ace in the wound care arcnJ Cre<sit'd u .. ing a var ie ty of tec hnique s and sub~Iall(;e..,. 11\ mg !'kin applll.:atiol1!) rese mble skin struc ture and IUllltlon and Ill.!) mclude e pide nnal and dennal layer~_ Skill "Ub"'IJllIIC.., arc of human o rig in or bioengineered IIS')ue The~ ale' u ..el ul a.., temporary cove rage, provid ing ~k m protclIi on Illr the \~ ound bed. Some have been show n to ~tllnulatt: C ndl)ge nou~ ce ll ac ti vit y. Most are marketed to U~ on \\\lumh lhal h,l\C not re::.ponded to convent ional Iherap) ur fur burn ca re. Selected exa mples o f prod uc t name .... thtlr ..,oun.:e l)1 ..,kin ce ll!>, and the type of wound the) art: u...cd 10 treal are found in Table 17.3, InnO\:Jth t' Urt=ssi ng!> \e\.\ pmliUd ....trt· emc-nng the l1l~trket yearly as research and dc\el orlll"nt lununUe 10 gn)\\ and e"pand in the area ()f wounJ lJle !O(, JIlJ.ll) 10 Illl'nl LUJl all , c~tlegories include opium ..... u"h ,j' PiJl~ "w... lIMfLde dre~~lIlg) . ab~oq)l i\e fi llers ,
hydrophili c fiber, composite dressings, collagen. and biological products, Exam pl es of products gaining attention are: • Hydroact ive dressings are des ig ned to have a se lective absorpti ve capac it y. They have the combined positive characteristics of foam and gel dressings. Their properties al low growth factors and other pe ptides to survive on the wound bed. Aquacel® (ConvaTec. Princeton. NJ 08 543 ) is a spun Hydrofibe r® dress ing that read ily absorbs moi sture (Fig, 17 .37). Aquacel ® Ag adds ion ic sil ver to the absorbent dressing. Flexi ble film dre ssin gs made wi th ch it in. a natural material found in the extrace llular macromolecules of the body. 192 Hya lofi tt -F'" (ConvaTec . Princeton . NJ 08543) is a hyaluronic ac id der ivative dress ing that is applied directly to the wou nd . First used most on neuropathic foot ulcers, it has been used successfully in a clinical trial fo r venous leg ulcers. 19)
Figure 17.37 Sample of AQUACELs , a H)'drofiber* dressing ~l mul all ng Ihe change in consistency from dry to gel as wound drdinage is ab'orbed.
680
PhysiC'al Rehabilitation
wo und s are prese nt. compression is essential for timely wound healing . For the individual with mi xed arteriaJ and venouS disease. an ABI test is indicated to provide information about the safet y of using compression on the LE. A greater und erstandin g of how the lymphatic sys· tern func tion s has c reated a paradigm shift in the way inte rve nti on for nil types of swe lling is planned and deli vered. Aggressive compression techniques were Once used to ;'milk the fluid out of a limb, It is now underslOod Ihal deep pressure and mechani cal " milking" techniques are co unte rproductive and harmful to the superfi· cial ca pillary network Ihal filters lymph and interstitial o
,
tluid s.~
Figure 17.38 Manuall ymphallc dr:lllHlgc: 10 Ihe LE. (Coune!)y of Klo::.e TrJmmg & Con::.ullmg. LLC . Rc:d BanI.... NJ 07701 .)
Manual Lymphatic Drainage Manual lymph drail13!!c (MLD) is a speciali zed Illanual the-rap) tec hnique' th at 3ffecb primarily ~ u perficial iym~ phatlc ci rcu lation . It is con~idered to be one of the five elemelll'\ of an erfecli, e Ire:llmenl mten ention for I) 01phedem:1 and 1n311) t) pe~ of edem3. MLD will increa~c the frequenc) of I) mphanglOn contrac tjon ~. imprmc I~mph tr:lJ1 ~pOr1 capac-it) . redirect I)mp h no'~ toward coll~ile"Tal \ e:-.'l'b. ana~1O!1l0~l~~, and ulll",olved I) mph T\~glon, and moblll/(, e\ce~:-. I~ mph Iluid that hJ'i m cr\~ helmed a hod~ ~egl1l(,llt or regillll. The (C'chnique ~ of MLD are gCllIle .:md "pct.:ltie. requiring ~peLiailzed ("due,llion II) ~ ~)(;'rlonll cd '1(;(,:urJ.h;·I~ (Fig 17.1H). ,\ppe ndi\ A prO\ llit' " l.:onl,llI In fonll..lll On lor IrJlIlIng LtcllHle . . Ilhlt prm Idt: "'peclali/cod l"dul.. ..tli on 111 \1LO and COT. Th ~ lx'n· \'1,1'. oj thl .., lrl" JUnl"1lI Me ntH limited 10 Ih(' Ih'pulallOIi "llh l~mphl"Jt."Il1;\ ~lL D ,.., U'l"U ... u('t:(' ...... fulh for l"lklll.\ hom ')'>1111' IIIJUT\ ;lnU 11lI ... lllper,ul\c ..,\\I..'l lIlIg II I' ron·
Ele\'ation Although elevation is not compression therapy, it is used as mea"ns of controllin g some types of swelling and is often a prec ursor to compression. Mild. acute swelling of the ex tremities ma y be re lieved temporaril y with eleva· ti on. Active ROM exe rc ises (e.g .. ankle pumps) can be used to f.cilitate blood now. Patients shou ld be educated aboul how to elevate safe ly. paying auention to positionin g so Ihal optimal ve nous and lymphatic circulation is facilitated. Elevation should be viewed as a temporary or com plementary measure while other means of controUing swelling are empl oyed. Unna 's Boot Co mpression for th e LE wi th a venous wound can be applied usi ng zinc pas te impregna ted gauze or Unna's boot ( Fig. 17.39). E"mples of co meniently packaged products are; Medi copaste (Graham-Field Inc. Bay Shore. NY 11706). Unna-Flex (Bristo l-M yers Squibb. Pnnceton. NJ 085,)0). and Gelo-c",t ( BSN -JOBST. Charlolle. ~C 28209). There is lillie infonnation in the literature 10 3UPpon the IOpicJi application of zinc for \\ound helling. Tht' ~ u cct"'" of ItU'" treatment applicJtion b most likely o\~ mg
IrJlnJII.."Hcu lor [rt:JIIII~ ,:.lTdIJr i.lIld pllllllOnJr~ rcldled
(olllpre.sion 111eraJl' t"lkm;1 nr I) IIlrhl'lk'm;1 I' lm il ..11 11..\ ,til t) rt"~ l\1 Ik.t!lIlg (dl..' l11.1 I1ll1 IInl) Inlllh'h \\llUnU hl',.tlllg 1"1\ "til dln~ rl~rtu'hH1 dl U"Ul',. hut ..I1"l 11l,llll\ .11(', Ihl'
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Chapter 17 Vascular, l,~mphat.i(' , and Integumentary" Disorders
68 1
10 Ihl~ wmprc:-"'Ioll. It i~ an inc)"pcns ive me:l ns of cove ring a \\()u nd. prm id in,g compre ... :.ion and ~ upponing the ca lf pump 10 cm pt ~ \eno u ~ hlood from the LE. Unna's boot is nol appro pria tt' for aneria l or mixed arterial /ve nou s ulcer'. There ll1a~ bt.' more comfo rtabl e and e ffi cie nt TTlelh(xh for treat ing ve nou~ wound s than w ilh an Unna '5
!:loOt. 1"1\ Four·L ;'l~er
Randage
S~slem
Four-I,t~C'r bandage ::0) 'tems h ave been assoc iat ed \\ ith
e\(elkn t Icg uker c1o~ ure. The) include a wound coveri ng \\ Itl1 Illl' fUllctl on.
PO!titioning P lh ill t>l lIn g
techlillj UC,> ,lie lI'ed to pn."\t: 11 1 or , up pun
r ' '-''~U l e
uller--. ~h v..:11 .1'> olher t~f'I."'''' 01 "Oll lll.... edt"III,I , I ~ IIl phedclll a . •Ind \ a'LuL.1I d l ... \1rder, r h", Illl pn n am J. ... pt'LI lit 1I11\~ n.cntllln a ... "ell .I!> PRO, . , Iwu ld nOI he Il\elklnl..ed Of tllh.k'rt" III1lJled dUlln!! I rl',UInt' nl p l,lI1ll1ng D ~\ I Le ....HU.J I c\.hn l l\lu.~ ...... clt!L·leo ... hou ld bl' nJnlp,lllhlc \\l l h
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the p, deSigned 10 .,1.11\1\\ I..h -.lnookd \\e l ~h lt)(.1nng lor 111d.\.jdultl~ "'utgl normOthcmlla 10 rcducc= the Inlldcnce 0 1 )ourglc .. 1 \\ound IIll c=u ion Hnd ,1I011en ho'pltaltzlIllolI ." Engl J Mt'd\34 12()4 . 1,)96 16 Allyeh BS. cl al Managemellt 01 ..lute and l hrunK opcn \Hjund~ The unporlitncc 01 11101" e n\-Ihlnment Iv UP1HllUI .... o und he,Jlm!! CUrT Ph ..ml BUJI ~ hnl)11179 2002 17 SvelhJu. T. el .1.1· A(leJeraled heJ.llng o lluJl -th l... ~nl." ~ .. Un ~oulI{h In d .... ('1 emJl"OllIllcnt Pla.,1 Rl'lun~tr ~ur~ 106(1): b02. 2()IJO
18. Eriksson. E. e t a l: Treatment of chronic . nonhealing abdominal wound in a liquid environment. Ann P last Surg 36(1): 80. 1996. 19. Dyson. M. e t al: Compari son o f the effects of mo ist and dry conditio ns on dermal repai r. J Invest Dermatol 9 1:4 34. 1988. 20. Lee, lE. et at: An infection-preventing bilayered colJagen membrane contain ing antibiotic-loaded h yaluronan micropanicles: Physical and bio logical properties. Artif O rgans 26(7): 636.2002 21. Thomas, OW. et al : Randomized c linical trial of the effect of semiocclusive dress ings on the microflora and clinical outcome of acUle bcia! wounds. Wound Re pair Regen 8(4): 258, 2000. 22. Madeo M. el al : A randomized trial comparing Arglaes(a transparent dressing conlaining silver ions) to Tegaderm (3 transparent polyurethane dress ing) fo r dress ing periphe ral arterial catheters and centrdl vaM;ular calheters. Imens erit Care Nurs 14(4): 187. 1998. 23. Koupi!. J. e t a l: The influence o f moisture ~ound healing on the Inc ide ncc of bacterial infection and his to log ical changes in htaltb~ human skin afte r treatme nt o f interactive dressings. Acta Chir Plast
45(3),89.2003.
24. Hutc hinson. JJ , and Lawrence. JC: Wound infection under occlu· slve dreSSings. J Hosp Infect 17:83, 1991 . 25. Nemeth . AJ . et al: Fastcr healing rmd less pain in sk:in biops) siteS trealed With all occlusi\e d rc)sing. Arch Demlatol 121:1679. 1991. 26. Mcchanic k, JI : PractlC:11 !I.!.per.:IS of nutritional support for wound· healing patierll). Am J Surg 188 (I). Suppl I. July: 52. 2()(». :'7 Shepherd. AA : Nutrition for oplimu m .... o und healing. NuTS Stand 18(6):55 .20003. 211 Gr.l.). ~t : Does oral ,upplemcm3.tlon with' namins A or E pnxnOk' hCJ.Jmg 01 ..:hlt)ntc "H)und,,? j Wound O)otOin Conrinen Nurs
3(~6),290, 2003 . 29. GrJ.Y,,\1; Do!.'~ \ lIamin C ~upplelllemation promote prt")sure ulcer hl!,Jlin!{' J Wound O)t.:'om Conttnen Nurs 30(5):2J5. 2003.
10 C'ollm,>, 'J 111c rig hf ml' · U:-.ing nUlrltlonal inlerventlonsandao J.l)abo1l..: l1genl to numage .:t. St41ge IV uk... r. Ad\' Sun Wound C!!1t 17( I I:}". 2004. \ I ('ollln~. N· Diabt-Ic" nutri llon and ,",oonkl, K, 3n .. on 111 chronic "OUIlCh-. Ostomy Wound Manage 47( 1): 34.200 I. 39 . Hard\. M: The ph)siology of scar fOnllation . Phy\ The r 69(22): 1014.1989. 40. Kir.ller. RS . and Bogen~berger. G : 11,e nonnal proce~s o f healing. In Kloth, LC. and McCulloch. 1M (cd ... ): \\found Hea ling: A lternatives In Manag~ment. ed 3. FA Davk Philade lph ia. 2002 . p 3. .n. Su~~man. C. and Bate ~-Je n~ e n . BM : Wou nd healing ph y~iology and chrOniC wound heJhng. In Sussman , C. and Bate:.. BM (eds): Wound Care: A Collabor.l!i ... e Pract ice Manual for Physical TheraPl,t' find Nu~e): We,und Care E, ~c nliak Pra.:licc Pnnc i p1e~ . Spnng hnu..,c PA' LIPPlllLOlt Wililan'~ 0.:. Wilk ln\, 2004. P 27 1. 56 BrQl.I~ .~. :lHd Burn,uld . K: The cau ~t' 01 vt'nou, ukerallon . L"'lkC! ~ 132. J')!-i2 57 .... olb..lli. 1)1\, c! al. S~'\erlty of \cn()Us IlhUffi('lenC) j, rd ated to the den'il! (.1 1l1!l11 )\J.\l·ulJ.I di:'po.' lllon 01 PAl- I. uPA ,md \'on \\llIchr,unil,ldol J \res~ urc sore mk assc,\smem : A cnllque. J; The Gosnell Scale. Decublti ~ 2(3):40, 1989. 98. Braden, BJ, and Bergstrom . N: A conceptual "chema for the "tudy of etiology of pre"sure sores. Re habil NuTS 12(1 ): 8. 1987. 99. Braden . 8J . and Bergrstrom. N: Clinical utility of the Braden Scale for predicting pre:"s ure ~ore ri ~ k . Dea v l~ . Philadelphia . 2002. p 27 I. 155 S lJ '~I1l ~ n , C. and 8 ) I. ~N : Ek'ClfICll l Mlrllul:tl ion for .....ound healIIlg In S u ,~ m:ln . C ::md Bale,. 8M (td ~ J : Wound Care: A CollaOOmil\(' I'T",IClICC Manu)!1 for Ph},lcol 'Il ll;"rap l ~b and Nurses. ed 2. A'llCli. Ci.lItlu: .... bu rt;. MD, 2001 . P 497 . 156 Sal/ht.'rg. CA. 1.'1 :11 The elTect of non ·thermal pulscd clectromagn... lll eOl'rg.y (Olapul ,c ) on wound healing of pressure ulce~ in ~rUl .lI lOflllllJurt:d patlt~nt ' : A randorlll/cd , double-blind Mudy. Wuund, 7(1 ): 11. 11)45. ' ~7 Hil l. J. ct:1 1: PIlI-.ed shun · ..... ""e dmthermy C(fects Oil human fibmbIN prol,krJllon . Arch Ph y~ Med Rehabill:!3(6):832. 2002. 15K Ma)Tll\ III , II . and Lar:.en. P: Efti'Ct s of pul'iCd e lectromag.netic fi elds on ~~In nI ICrt)\ ,l'oCular blood perfu!>lon. Wound~ 4/5): I97. 1992. 159 Conner· Kerr. T' llltr:l\'lo lcl light and ~ound heal mg . In Sussman. C and l:bu:,. 8 M led ~ ) : \\-'ound Care: A Collaborative Practice Man1,1 3.1 lor PiI)'Kdl TherapIst.!> and Nurse,. ed 2. Aspen. Gatlhcr~burg. \10. 2(J(1I . r 5&C)
R :u",~). C and ChallOl1{'r, A. Vascula .. e hange~ in human sllll after Ultra.1 !Olet 1rrJdl31lon. Rr J Dennalol 1)4 :487 , 1976. 161 Hi gh. A~ . and IIl gh. JP: Treauncnl or infected ski n wounds uloing ullr:1I IOlt'l radHlltOn' An In VIIrO study. Physiotherapy 69( 1O):35\}.
IflO
1 9K ~
161 CUIUlt'r· Kcn [. \:1 al. 'n\C effC\.-L,> or ultr:i\'iolet r;U/ialion 011 antibioticre'J,lo.uU h.... lCna III \ Ilr(). O;tomy Wour)(! Manage 44{ JO):50, 1(19ft 163 Conncr· ... crr . l cI "I. UVC reduce, antlhioIlC-rt:'iilol.anl baclt~nal numbt'r. til lt ~ tng 1I';.~u e. SAWC Se lected Ab.!>lrat·tl>. OSlomy \\'ound \ 1.1I1:lgt' 451S4 . 1999. I", Thai 'J t'l "J l'Ilr,,\ IOICI lIg.ht C m the In:aIOIl.'nl of chromc .....ounds "'Ith MR';A A t. a~ ' Iudy. O~IOnl y Wound Manag.e 48(11):52. 2002. (,e rOhetnu ~. R. cI al l l ie cfl ect of UVC and UVB on epidennal ~\Iund hcahng e lm R t'~ .sO: 586 A. 11)82. !\ llIdh"d I t'I..l1 ~1t t:L""b 01 ul!mvloletlhcnlpy on f'd1 skin wound hClll mg J ';u rt! Re ~ 4X. M!. 1990 167 11(.\ 1.111 ) \ 'nh~ nllrtl OX ide connL'"C"litln : lIypt.· .. baric oxygcn Ihcr· "r\ hu .ll'it:rmm "nd d,abcl ,t. ulLer managemt'lil. Adv Skin Wound ( JI", ) \ lUI 21 11'11) (jUIrIIII .. A ,lnJ VIII.M.. A The d fcci of h}perb!tnc o xygo:n on dif· k lt'rlt plld"" \,t he.:.lllig Qr 1!!p,t,-. he mK ndp wnund ~ and lIlciMunal ""Jur,J til ~III Hr J PI"-,, Su r~ 4 K5!S~, JC)'.)5. 16'1 l..."ll t ~'I U \\ A t'l .. I' J- vJlualll)J1 01 h) perbarll oxygen for dla~lic "'OIunJ A rr" ,pcl ll\t' ~ I ud } . l nder..cd lI ) perb Mcd J 24' 175, I'N7 170 1J ~'mu drlu!,,1 ( dwl ~ u ndt::fhO: II:. 'I . lI y relb~riL (Jxygcn reduced '. 1/ , ,,1 l,r')ll1l k g ukeh. A fllnd.)fnl/.cd doubk -blind sludy. Pla, l
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', UQIJ . J'}\)~
I\ Ii ) pt:rh"ll ~ I) ;\} gC11Iher.lp} A ph Y~ lolog l cal IIPI>rwoch 1" .... 1,·, 1,'.1 prIJI.It' 1I1 ~ ound ht-.. ltnf Wounlieripher.il neuropalhy: A double-blind, randonli,xd, placebo·cootrolled study ..... ith monochromallc near- infrared treatment. Diabetes Care 27( I ):16K. 2004. 188. Powell. MW, Carnegie. DE. and Burke, TJ: Reversal or diuhct ic l)Cripheral neuropathy lind lIew wound incidence: Thc role or MIRE. Adv Skin Wound Care 17(6):295.2004. 18:9. Noblt. JG. Lo.....e. AS. and BllX tcr, GO: Monochromatic infrared irrddl:ttion (890 nm): effecI of a mullisource array upon conduction in the human median nerve. J Clin La~r Med Surg 19(6):291.2001. 190. Burke. 1'J: 5 Que. . uons-and an~we r~about MIRE treatment. Adv Skin Wound Care 16(7):369,2003. 191 . Prenderga.o.l. JJ , Miranda. G, and Sanchez. M: Inlprovemcnt of sen· ,ory impairment in palicnts ..... lIh periphera l neuropalhy. Endo!.·r Praet 1(}(1):24, 2004. 192. Yu ~o f, NL. CI al : FleXible chitin film.!> as polential ..... ound ·dres~rng materials: Wound model Mudie~. J Oiomcd MUIc.r Res 66A(2):224, 2003 . 193. ColtCttli, V, et al: A lrilll to a~ses~ the efficacy and rolcmhrlily of Ilyalotill -F in nOIl ·healing vcnou . . leg ulct'r!.'. J Wound Care 12(9):357. 2003. 194 Suos!>enreuthcr, RHK . Ct al. PractrcalluSll1lclron, fO(Therap l ~b ManuaJ Lymph Dnunage A ~'cord m g 10 Dr. E. Voddcr. In f"01J1. M, Foldi, E. and Kub,~ , 5 (cth): TC'xlbool ot Lymphology for Phy,, · Li:tn~ and Lymphtdcm:t TIIt'raplMs, cd 5, EI~\' ler GmbH. MUIIICh, Germany, 200~ . r ~t)6 . 195. Frall1..eck. UK. cla l. Comhincd phy .... eal thcrapy (or Iymphcdcma t:\'UIUIUcd by fluurc o,ccncc 1lI1{'rol)' Ulphogfilphy Wid Iynrph ,·ftp il lary Jl rl·,~ ure JlIC:l~ufenlc n K J Vascul Res 34 .306, 19')7. 1% . II w:lI1g. HI. el al ('h .. nge, 1Il1}lllphulK fUJI~' 1I011 after coillple, Jlh )'~ icallhcrapy h,r Iymphedt'ma. Lymphology 12 l!i , 11)1)9 IIJ7 kol)t•..-.n. r-.·IC Trt .tllIl~ bat tcn ..1 rnft't.livr\) in dUOIII( wlJu lld~ . Cellltemp 'iurg SUPI)I SCjw t J. 2(0) IfJtt Kul \al. ( '. and Bllzl..un AK C'OIl1hmalrl}f1 {II h)dnxol luid dre . . Mng and n \e. hcallOlH~,n:"" ' IOfI \",lo.llIg' VC"\I.) Unlla \ ho..IOl for tDe If~at · Ul("nI of Vl.'nUII~ Icg lIkcr, ~W I ~' ~1L'd WUy I \3(2"i 16)..164. 10.1.1. It}I) Mnni1t, CJ, d !ll RanJ"UllIcd tnall;(Jlllpanllg t .... u IUlirldyec ~/Id :rge "y~lclU~ Iflilic II1.UlUi\Ctue.1II of ChfOrU i.. leg uk.er.ltlun Phlebology 14; IJl), ILJI.~J
692
Physical Rehabilitation
200. Leduc. O. Peelers. A. and Borgeois. P; Bandages: Scintigraphic demon~tration of it!> efficacy on colloidal protein rcabsorpuon during muscle aCli\'ily. Progress in Lymphology-XII . Elsevier. Philadelphia. 1990. 201. Johansson. K. et al: Effects of cOlllprc~~ion bandaging wi th or wilhOU I manual lymph drainage treatment in patients with po:o.loper:l tive ann lymphedema. Lymphology 32:103.1999. 202. Schmid-Schonbcin. GW: Microlymphatics and lymph now. Phy-.iol Rev 70(4):987. 1990. 203. Simon. DA. Dix. FP. and McCollum. CN: Management of \'eIlOUs leg ulcers. Br Med J 328: 1358. 2004. 204. Wei'is. J: Treatment of leg edema lind wounds in a patient with severe muscul~kelctal injuries. Phys Thcr 78( 10): 1104. 1998. 205. Asmussen. PD. and Stros~ n reuthcr. RHK : Compression themp),. In Foldi. M. Foldi. E. and Kubik . S (cds): Textbook of Lympholog.y for Php.lciam, and Lymphedema Thcr:lpists. ed 5. Elsevier GmbH. Munich. G~rnlany. 2003. p 528. 206. Ya:)uhara. H. Shigematsu. H. and Muto. T: A study of the advantages of cla)".ti,· slockin!! for leg lymphedema. Int Angiology 15(3):272. 1996. 207 . Harris. SR. el al: Clinical practice guidelines for the care and treatmenl ofbrea~1 cancer: II. Lymphedema. Can Med Assoc J 164(2): 191.2001. 208 . Badger. CM. Peacock. JL. and MOf1ime r. PS : A randomized. controlled , parallel-group cliOlc:tI trial comparing mull iplayer bandaging follo""ed by hosiery \'ersu~ ho si~ry alone in the treat ment of palients \,\ ilh lyOlphedema of the limb. Cancer S8t12):2S32. 2000. 209. McCulloch. JM . el al : IntemliuCIlI pneumatic compre ...sion enhances \enou ... ulcer healing. Adv Wound Care 7(-'): 22. 1994. :no. Berhne.r E. Ozbilgill. B. and z.trin. DA: A system,Hic revIew of pneumatic compre Iraighl acrm)\: do not c ut into corne rs. U~e an emery board for :-. harp edges. A pumice s l o n ~ ('an be u')ed to IreJt small co rn .., and ca llu ~e~. Alen
Check Your Shoes I . Check your shoes every day before you put them on. Look inside for small things that could cause a sore on your foot. Alternat e shoes eac h day to all ow them to breathe and dry completely. 2. Be sure th at your shoes are the right size and width. 3. Do nOI wear old worn -o ut shoes or socks. 4. Shop for shoes in the aftemoon when your feel are the largest. 5. Break in your new shoes gradually.
See Your H ealth Care Provider I. Get he lp in controlling your diabetes. 2. Have reg ular appointments \\ ilh your doctor. 3. Call )our health care prov ider immcdialel y if you find a wou nd on you r fOOL
Appendix C: Special Tests for Arterial and Venous Function 'ipc'L1,tll ~," Rubor of d e p('nd e n c ~'
A no ninvas ive test Ihal examined the LE for the presence of ischemia. Follow ing elevati on of the limb. loweri ng of the limb should return the skin of the l imb to a pi nk color. If th e color is dark red and tak es
more than 30 seconds to appea r, the lest is positi ve for art erial insufficiency. Air pl ('th ~:- m og r;;tph) ( A PG }
A n onin v J ete c t~ d unde r the dbla l pa lpil ti oll site, thi .., indi cate s the poss ibil ity of va lvular incolll· pet e ncy.
---
Te ..;t mea ') ure s the lime req uin: d to refill the veinl> in the: dOf"u Ol of the 1001. T he LE i ~ e levated 10 all ow venous blood to l: I1lPI Y. A toum i· que t o n the I h ig h preve nt:, bac Ul o w. Aft er I mi nute . the Indi vidua l ~ t amj... . I f ve ins fu ll ) di ..,h: nd \\ ilhi ll :) ~el:ond ,", be fore Iht! [l)urn iq uet I ... rek'a..,l:d , va lvul ar iIKom pclt' nl.' C ill the d ~l.' p ve il}'> I ~ :-,. u ~ pei.: ted . I f JI ') ICI1l1 0 n o..:-cur... w ilhin ;) ... ('co nd ~ afte r the tourniq ue t I!I re k' a ... ec!.
II1t:o lll petenlt; of ... uperfil HIt \CUl'. I.., ... u ~pe (.; l e d
Appendix D: Pressure Ulcer Scale for Healing (pUSH) PUSH Tool 3.0 _ _ __ __ __ __ _ _ __ _ _ _ __ _ _ _ _ Patient ID# _ _ _ _ __ Patient Name _ ________________________________________________________ Date ____________ Ulcer Location
Directions:
Observe and measure the pressure ulcer. Categorize the ulcer with respect to surface area, e~udate, and type of wound tissue. Record a sub-score for each of these ulcer characteristics. Add the sub-scores to obtam the total score. A cornparison of total scores measured over time provides an indication of the improvement or deterioration in pressure ulcer healing.
0
LENGTH
0
X
WIDTH
(in em')
1 < 0.3
2 0.3-D.6
3
4
5
0.7-1.0
1.1- 2.0
2.1-3 .0
6
7
8
9
10
3. 1-4.0
4.1- 8.0
8.1 - 12.0
12.1-24.0
> 24.0
2 Moderate
Heavy
EXUDATE AMOUNT
0
1
None
Light
TISSUE TYPE
0
1
Closed
Epithelial Tiss ue
2 Granul ation Tiss ue
3 3 Slough
S ub-score
S u b-score
4 Necrotic
S ub-score
Tissue TOTAL SCORE
Length X Width: Measure Ihe g realesl length (head-to-toe) and Ihe greatesl width (s ide-to-side) using a centimeter ruler. Multip ly these two measurements (length x width) to obtain an estim ate of surface area in square centimeters (cm 2) . Caveat : Do not guess! Always use a centimeter ruler and always use the same method each time the ulcer is measured. Exud ate Amount : ESlima le the amounl of ex udate (drainage) present after removal of the dress ing and before applying any topical age nt to the ulcer. Estimate the ex udate (drainage) as none, light. moderate. or heavy.
T issue Type: Thi s refers 10 the Iypes of tissue that are present in the wound (ulce r) bed. Score as a "4" if there is any necroti c t i ~sue present. Score as a "3" if there is any amo unt of slo ugh present and nec rotic ti ss ue is absent. Score as a "2" if the wound is c lean and contain s granu lation tiss ue . A superficial wou nd th at is reepi thelializing is scored as a " 1". When the wound i~ closed , score as a "0". 4 - Nec roti c T issue (Eschar): black. brown, or tan tiss ue that adhe res fi rmly to the wound bed o r ulcer edges and may be e ither firmer o r soft er than surround ing ski n. 3 - Sloug h : ye ll ow or white t i~s ue th at adhe res to the ulcer bed in s trin gs or thi c k c lumps, or is m uci nous. 2 - G ranu la t ion T issue: pi nk or beefy red ti ssue wi th a shi ny, moist, gra nul ar appearance. 1- Epit hdial T iss ue: for ~upcrfi c i a l ul cers, new pi nk o r shiny ti sl)ue (sk in ) th at grow s in from the edges or as is.lands on the ulcer surface . 0 - Closed/ Resu rfaced : the Vvo und i ~ completel y covered with ~pithe l ium (new s kin). --- - - - .- - ---- - ------- ----. - - - - - -- - -- - --- - --www.np uap.urg
PUS H Too l Ve rsion 3.0: 9/ 15/98 ®National Press ure Ulcer Advisory Pannel
Pressure Ulcer Healing Chart To monitor trends in PUSH Scores over time (Use a separate page for each pressure ulcer) Patient
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Patien t 10# _ _ _ _ __
N~u n e
Ulcer LOC3tion
Dale _ _ _ _ __
Directions ; Ob~e rve
and measure press ure ulce rs al reg ular int e rva ls using the PUS H Too l. Date and record PUS H Sub· scores and To tal Scores o n (he Pressure Ulce r He alin g Record be low.
-
Pressure Ulce r Healing Record Dale
-
Len glh X \l"idl~
-
bud afl' Amo unt !
Tissue T) pe I
PL'S H Tota l Sco;e -
!
.--L
Graph the Pl' SH Total
Sco re~
o n the Pre!Iv ng _.Jdgm:':"'J Dlll1imshed >rculo,l.:eletal pam as"'Clated with mu""le IIIld ligament ~tralO can develop from mechamcal stress. abnormal po tu,es. and immobility, often the result of weak muscle, po"crful spa"'"'ty. and tonic spasms Anx,elV and fCJ!c:o worsen pain ~ymptom'\. ~
lion
Inp.:.:;rcd ability to ilI'hlcve ,-'rga.~"ID
Bo"el S\ mptoRl..'i (C'nstirati~
Dial" 'lej InC:::;11;ne:tce
Visual Changes
Speech and ~"allo" ing
Dys.anhna Dimini'5hcd v.:' "'11 fluc:nc:y
Vi I\·.menl c! t optic nerve produces altered VISual tlcity. blir:=rare Optic IZellr!'s. nflrunmatico of rhe optIC Del'\·C. \:j J common problem. and produces an ,ce yIek Jee I" bc'!ind the eye" ,!h rlu:-ring or graying of
ma
D,"'-:\~':!~
Dy::-;hag..1
CardiO\;ascular d.,sautonomia
'"":"
''''OIl,
ness In cue eye A U"ottmUl or daJi;. spot ma,\ ' tX-~:::; center of lite \' isual field. ~eur::'::':' ra7tly C~:; I:r~ c
Pallern of S)-mptoms
ant' IS u. _
IPI "
_
,',-.
;!'_,.Jr~.'J(~·,;-:",-,·,·'~-~,'J9~}"-'-·""> " ,'~~~':r~;5l~,:{,_;,:Y"~~';'M':L_. " :.!f','l~/j~"- :""~.-"; -,',' .
iii,, , ,"
_.~_~
,.,., ••
1'' ' "'.Ii',"''''~~"l'.t!:;,;,ys ...., ., ,.,'" ..; . '!~~~~)~"":-~"ft"c,';:')"'"
IiIiI " "
"", ' II!II ' "
l'~,:!'~=,~ :':ia\t
'e
'~5' ' , . '
........... iNli.ln'k_ ,,., ;: . ;; . 4 ~::-",;:"",-: ,\,, ~ r_~ "(.~ '~"-
$1 Aailyofdh "1 . . . . . . . . _ . . . . . . . .dIat is, i!ldivi'l miIIlJy • I
~ ...
'1" '"
~lJi!Ii'~n
'1t.
.. .. pa"- ...
,
(abnormal ~~ \ (MRs), CIOllUI. t'IeltIOIIor.1I1l iT I ,;' de 9(, perrent fof lIl
~'-;"';;;~'IJ;"': Onsct wah ntl)' one
5)'ffiptom 11
one of the
stron~ t;'":~'..:ators of a favoratle prognocis
<J due",,, Ikm;:. and RKMS are acsoclalC'J \;-,!!I .~ mor::: "avorable ~'gnOSIS whereas PP~fS l~, gfn Iy con'Jlkred mo:e :mmow> Young a~ .11 onset is more fay; )rahle .hat! ~nset r .":,= 4t '. ~·"ti( l:'~ &SKlC-=::cd wlth.e PPMS CUUrSl: and
~~j c.:~~:_
'
uur.J ..if: one 0'1' the: rl, rlC"oo"'l, c.;':lfH ml pvranuda! and Vemenl d.: mU:~lpl(, tiLes at orl 'A'lIh II pocfcr Pf-;.=ll;::-:;' and:ll"'fC "11 ...
:~.
r:::;;r ~~. pro~ostH.; factor ·!1f :!ldc 14;-';" L£ll''-~ : =:'I~"~ fnl":'71a:.~or:
t-.L-:1:-'
I
Disease-Modifying Agents Ad\ .UK·t::-, in ph~mnacolherapy havt: pmdu(cd !I)nthetk interteron drug, (interferon beta· I b IBetaseronJ. inletter"" beta J·a IA\one\ and Reh,!]) Ihal have \ub,(antiaJ mununomod.
vlatmg propcnic~. These" an: clOse cople, of a llaturnUy occumng human chemica]. mlcrfcron }:leta. Imerferons S1 of MS can be reduced or prevented while 'lUaIIlY "' lile IS enhanced_ ,--, AccordlDg to l"e 1\ation31 \IS Society's "edlC,,1 Ad"",,), B=d. rehabwtation referral ,hould be lIlih.ted " 'hen",,,,, the~e IS an'a~rupt 0' p.ldual worsenlDg of fune lion or anncte3SC In Imp:unnenl that has a Significant
Fibrosislankytoata
input
Slooi souencTS (JI0Ctyl . . odlum ... ulfo~UI;I..·irlatc IC()L.u:cp. Rt'gullr OJ ",mtinuous use l)f slimulant !:l\JU\c ... and ene-· m:c; IS nol r-cCf"lmmend('d Inc(mlmcnl.:l" O1;ln;Jgcment indudc~ dietary (Jlangc'S ~ul.:h n... JHlidaTKc of Irritants (,-'.affcine, akoholl. adju .. tOlcnt of mcdil...',uiol1s u ...cd to redu ...-e spa_'itil'II)' \\"11](h can contribute (0 the problem. or dJdilwn 'If mcdlL.ltions In ('ol1lrol nowel ... pa ... m ... (tollao-
MU8cutosketetai OsteoporOSis
Neuromuscular
Integumentary Skin atrophy
Decubiti Chronic sepsis
Figure 19.1 Chnical Iflanric-stalions of Ina~ti\ity
facl be the rno,1 rneamngful outcome for patient.< m the face of ChWIlK neunxle£e-ncrauve' disease. Prel'('llIotn't' mlen'entum j,.. aimed at mlnlmlzmg poten· tial compli'-Jtions. irnpainnents. functional limitations. or dlsablliues a, the disease progresses. '11115 mdudes prewotion of. disea,e In a ,usceptible or potentially susceptible population. tenned primary prrl'cntion Pl't-venl1\'e efforts for the patienl with \\S geared to".u-d Jecre3StDg the duratiun and severll)' of s)mptoms or delay Illg the emer· gence of disease
;;p ,- IS de'tined h
~
fUlU.'i
(In t'e:
KrK"" c;t·J·Jtltla.l ,)(" 'I
I:.Clj'\'h,~S dC'~I,i!ntd tu fI1Jlntak; !'i1:- pallent s ~'ilrn;nl k,.,(J ,ll fun!';
,'.:t!:.lJ
t"duc.:.i!;,Oft4l,
:j:'~"j;j "'"'nh M" who bcn~tll ("'.)01 !llaJnt~nan\.(·lh('r:tfl I~ :..U~ ~ta~C"s llf rile .jjq,-.lSC ,I- I )YS
I pu. 1.1l'i arc II, j
k.'1i! dtJnfl'llisUoltln:
Chapter 19 Multil)ie Sclerosis ~(l
III
:".1ainlenance programs are typically not well ... j> j b, nn\ute II1surance. Medicare. which covers servtUll l .. l • ~ IC~~ fl,r the elderi? JJld .the disabl."d. wi Il ~o:cr maintenance \).5).
if the sl.;l11s ot a therapist (specialIzed knov.:lcdge
lr'. ilnd judgment) t h('n
are needed to manage a patient bec~lIse ,of kllulied dangers. For example, nsk of secondary nnpalr~lelll ~lnJ l(l~s of functional capahilities is reduced or safety of CJregi\"ers i~ enhan~ed. The. therapist examines and evalUJlt~" the ratient. deSigns an mlerventlOn program approri~lte to the capacity and tolerance of the patient and the ~bie-c[iW~ of medical management. implements the plan of c~. and periodjcally reevaluates the plan as required by the r'ltienl·~ condition. A varielY of interventions are used w 3.chle\'e goab and outcomes. mcluding limited direct inle-r,"enrions, patient/client-related mstruction. and !>uppurtJ\e coun ... eling, The primary focus is to teach patient~, faIlUI). and careglver5- the management ski Us necessary to 74 "7:> seven neuropsychulogical tests examining proce~sing speed/v.orking memory, learning and memory. executlve function, ,isualspat tal processmg, and word retneval. The MACFl\\S takes approximately 90 minutes to adnunister. '7 A I)rh.:-t" .;"creen of (;ognnivc function can t'Ie J(;hi~\ed using the ,11m; .Hental St.uus E1Jm I.III/St.) ,
Brause many dJlf=t are-4S of the CNS may be afteded. Imperative that a ,"":~··eful exarninat.on JS ptTlunne-J to
,\fi'ecthe and Psychosocial Function
diseases.
dew'mine the ex~("nt .-::::1 neuroloiPcal and
Ivement.
SubSC,qUCHl fe·C"'UlT'.... nsttl~ rhe elftXlS (11' fat~ut'" no ("cgnulve. physicjJl. tlnd pSYChll:,(l
"ii.tl funciiun USing a ) POlO[ ordinal s,,'a1e \\- ~th [) eqUi11 t~1 nevcl and 4 t~uJ.1 to ulmost U}\\iJ,ys, Ea\.·h are:l (s ubSCllr' ,an be "'ored sc-paratt'y; the kltJ1 \lFlS s,ute rlllge " fm~ II 10 84 (.~ Apt'enJx A). Ihe , \I FJ~ con t>c down, leaded III I'DI' rOnllal from hup:t1w\\" ,n3Lon:l1rns~"'tet), l'rg/\IU("S f.tiguo asp, An fiH't'e""leti ,'c",,,r of !i1' \'lrIS til\> five item" nh• .l1f"H 5)
Chapter 19 '-Iultiple Sclerosis
TC,J11pcf'atuf'C Scn~ith'ity The J,,1P'-~ (lllC'Olrcrature -.emtlivlt) and its clled {lJ1 latlgue
and w('3ko("s' .. hllUld lx' c\aminctl A tympanic 1l1t:l1lhr..mc (hCt111(lInt'fC'r (car IhcrmoTlWIC'r ) can he used hcfore. dunng and after m(x1er;!h.·-in(~n .. lly c'ercl~ A defennlnation of the ~~I.1tillJl '~I"t.'Cn temperature- t.:hanges and y.ol"'enmg of ;;urol(l~I~,:;ll ..ymplonl' can be madc. '-'
\lolOr Function 'J1lc:' ;:he-rapisl
~h(luld CXJmml'
for the presenl'c of C{lfl i. t.'osptna! !l.lsn, (p:lrc .. ", .'pastll'it). hyperactive DTRs. pos· lun'" Rahin"k,"., sign. and involuntary spasms Iflexor or e\fcn .. orJ). The'\ml'lId,'d MOlor Cluh E\Ulllinalion , .
hpand
Pr"('\wtr'·r('/llTlng tie"II'l"" (PRJh) may he neCCS~arv tc prole,'I InSCIl'ltlvC - ' arc:a~ . and shtluld he ImplemCTlI . ed a\' ' Thc . . e C~1Jl IIlcludc m;'ltlres$CS (water 0''"'1 itrpJllpn at t.: _ . . ' t-'- • alt 'rn"'lnf! prcs~urc) t,o til,lnhute body weight ' II
or~It:·~
'.
-
_
.
and
rl'dUCc "h\:ar and fricJ ph)'il\ll\.\.~h.'t\1 fCl'ipOU-:c't IU sUhl1l'I\I111;d ,1~'I"lIb.c ('Xl'll'I!l.C'. Ih:lt is, hl".II"t
1;t1r. 1111":'1. !I!lltld
p"L'"sllr~
(Bit).
,!lliJ (l\~~l'll upta~eCOIldary tmpamnnts .u.~ as -:;0,. '!C"', postural deform,ty, and deru:'UIlS ulcc:> c! phy"....1 thcr:!py L·~.. nuons C:IT1 be u:'::zed. ::!:.t~-.; ctYOIIlorapy. tyd!-.:.ther!:". th.,-Jpc"": e eY.r"_'se f Th;: r>p'.ln -J do,.,ly and nter.'entlons. f'lt ~ lilt anL!.;-..=!' -'.1 the"
· m,nules or hours, It I"; importJOl tt, :emembcr ft.. •• I t1f . . . ut4i . . t • ,ts rartlcularly thesc '" Ith mtact 'SetJ;~tIon ~ .. , some p.l lei '. . ....... ," unpleasanf scnsauon ,)f cold wlth/ith, '.Jr fIU)L read to 'he 'JutonOmlC nen-ous svsteO") resJX"nses.. S;Jl::h us Lncrea~d heart ratc respiratory rate. 0r nausea Cryotherapy rna} be c,.,mtr.llOthcJ.ted in thc-e patients, RO~f exerec,",' ""gun eJrlv In the .cour", ,··f the J,se.s. and (vnunued daily tan hc:p pallenh malOLJ.m JOin~ t 'gntv and motiliT),. In the f.'J.cc of anr:r"1Jt1 l ng J;pastiCit". me . . ' d J strctchtng tc(hmquc~ are IrdlC.ltc to mc.rease exten"lbslib (lr the mlLo;;cic tcndtlO unit and ",onnccllve tissue Intenn1ueqt ,~tlic >!relchmg held u "irumum of,O to 60 "'CG~1, ohouk! he applied. ,dc.llly for 5 to 10 rcpel,lion" (..mbining stretching movrments With rh)lhTn1C robt!on (gentle ~cxa. lion of the I1mh' or P'
er C'f body rnts .....:;=;.:f flttdom~ rI:rat ::Jusl he )11ed. se tec:-ruqt:!'s thaI....", be use. P~tllents frequently repon dlfticulty hlting their legs (hIp no,or w«lkness). Weak dor·
siflex.or ... are also common. resulting in fo~,)t Jrop. Problems \\'Ith foot clearance may n.:-~uh in a clreumJutteu gait pat. h:~m.
"lJ")
Later prohlem, evolve OWing tt) clonus. sp3Sticny. sellloss. and!or ataXIa. Weakness generally extends 10
Box 19.6 Frenkel"s Exercises ('C'nc:ral instructions: i ~cr;. 1st::. can he pcrfonnt'd ",llh the part liOupponr..:t1nf un....upponcd. UOII;,h:rJlIy ('f I'tll.ul..'ralh,. lky should pr.4:~-j., 1>m.)otk tir.1!'"'VC'~s 10 MOrpU1~ ~d H.. lrlln~ on comrn..mJ, 1Ik.'re:mnf thl.'" (.Ill"" ;md ~rf"rmln2 tht onccntration In.! 1"(:pc/iIIPn JIc the ~.::.\~ Itl succ('\.\, -\ '\11111101f pm"
, H···· Il
.'
ld !xi..,;
!l'"'
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Chapter 19 Multiple Sclerosio;; .1 Ie the qumirin'ps and Illp abductors. Quadriceps
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kn('~S n pit'alh n:sult ... III hyperexlensJOn of the knee 1'C'J"r 'r\\ •-".j nt'\i~n of tht' trunk wIth increased lumbar lor;itl (
"'11 ':ltxiuC'wr wt'.IJ...ncss result:-; in a Trendclcnburg . ·,tICnl with a strong latC'J'al lean to the weak side, ) I £:11 I' . . • A well-designed exercise program of tone reductIOn, d('''IS.
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stnmglhcl1ing exercises can improve gait. Jill!! ami walking ;;Klj\"ltic~ should strc. Mi safely. and · St;\n • .m;l1· ·n[·,lnmc a slclbk base 0f "upport: maximum wClght.. bCJnng through the LEs; and adequate weight tr'Ulsfer and fo(V.ard progression \\ nh trunk. 11mb, and peJvic kinematIn con,lstent with nOnllaJ walklOg. Verbal and manual
l"Ucmg «111 assist dlC pafu~nl in the con'eel mechanics of 12;111. The pool is an important medium that can also be ~.. ed to a~~bl training while reducing tone and fatigue and (lnLrolhng for ataxia. L~Kl)mOlOr training lIsing an overhead harness to supP'-lrt ~) _weIght and a m~ltori7ed trea~mill has been the f(x-'u~ L1j mcrea~mg atLenflon 111 the literature and used e\tcnsl,·ely TO Improve gail In patients with spinal cord JIlIUf) and .... trokel.~O"l...~ (see discussion in Chapter 13). '\rpIlC"dflOn to other chronic neurological conditions is liml!,;-d hut emerging. ~."4 Thi . . ta . . k-oriented intervention was u'-t.'d a." part of;1 comprehensive 12-week program by Fulk 10 unpRWt' gail speed, endurance. and balance in a patient with \15 (EDSS ,core of 1.5).'" The amount of body 'weIght ~upporl was reduced (.:!O percent to 0 percent) while ~"t'reed mcrea,ed by 21 percent (10 meter walk test) and 24.0 percent (6 minute walk teSl). Score, on the Berg Balance Scale (BBSI. and AClivi[ies-Specitlc Balance Confidence (ABC) ,cale, and the Modified Fatigue Impact S,-;ile-- 5·nem tN 1~1AS·:;) aho Improved. Perhaps moS! unporunl of all. the patient reported feeling safer and beller abk to engage in dally ~<X:laJ activities. Thu~ this foml of locomotor lraining appears to be a feasible and safe Intervt'ntion prodUl:mg .'Ignifk,mt positive effects and ,kservm.g 01 additional researt'h. Paticn~ With 'is lypH~all)' relJuire onholic devices a . . .unbulaLon fLu', decline Allkle· fOOl bt"b,lny can be achieved b) the nddiuon of oln all1.Ie· f(~lt ortho>i, (ArO), Improvement> ::.:."1 ene'l!Y rfflclt"'nc), and safety are :t1so Imponall1 OUh:0mes. Ai 'Os ~re prt.~Ill( .:la[O
